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. Hemogram   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Hemogram
CPT Code: 85027

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 Smears

Cause for rejection: Specimen hemolyzed, clotted, diluted with IV fluid, or collected in heparin; tubes improperly filled; specimen at RT > 8 hrs or 4-8C > 24 hrs

Storage: Refrigerated

Availability: Daily, 24 hours; STAT

Methodology: Impedance measurement with Optical Flow fluorescence measurements and Spectrophotometry

Special Instructions: Indicate clearly if a specimen has been drawn from an arterial line or from a line that has been rinsed with heparin.

TAT: 4 hours


Lab/Phone: 330-543-8416

Additional Info: Reference ranges are 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: