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. Blood Smear Review   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Blood Smear Review
CPT Code: 85007

Specimen Type: Blood

Tube Type/Collection Container: Purple top (EDTA) tube: Whole Blood

Collection Volume: 2.0 mL (minimum 0.3 mL) and 2 fresh peripheral blood smears

Cause for rejection: Specimens which are hemolyzed, clotted, diluted with IV fluid, or collected in heparin.

Storage: Refrigerated

Availability: Daily, 24 hours

Methodology: Microscopic evaluation of Wright's stained blood film

Special Instructions: A differential from whole blood cannot be done on a specimen held more than 4 hours at room temperature or more than 8 hours refrigerated. On microsamples, the specimen cannot be used when it is more than 4 hours old.

TAT: 4 hours


Lab/Phone: 330-543-8416

Additional Info: Reference range is available on patient report

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Ingrid Hershey, Laboratory Administrative Director, at 330-543-8721.

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


Physician Signature: Date: