Department of Pathology
and Laboratory Medicine

Akron Children's Hospital
One Perkins Square
Akron, OH 44308
Laboratory
Ph: (330) 543-8573
Fax: (330) 543-3659

LABORATORY TEST REQUISITION


PATIENT INFO
Patient Name:
Medical Record #:
BD:        /        /              Sex:    F    M

PHYSICIAN INFO
Physician Name :
Address:
Ph: (        )        -              Fax: (        )        -              
Additional Report to:
Ph: (        )        -              Fax: (        )        -              

TESTS REQUESTED
Test Name: ICD9 Code: (required)
1. Pseudocholinesterase   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Pseudocholinesterase
CPT Code: 82480

Specimen Type: Blood

Tube Type/Collection Container: Gold top SST (serum separator tube, no anticoagulant)

Collection Volume: 1.5 mL (minimum 0.5mL)

Cause for rejection: -

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Enzymatic

Special Instructions: Remove serum from cells ASAP. Plasma values are slightly lower than serum values. Specimens must be drawn prior to surgery or greater than two days following surgery. Do not draw in the recovery room.

TAT: 2-6 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: 2900-7100 U/L Days Performed: Mon-Fri

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Cindy Maurer at (330)543-8689.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: