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. Alpha-Fetoprotein, Serum (Tumor Marker)   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Alpha-Fetoprotein, Serum (Tumor Marker)
CPT Code: 82105

Specimen Type: Blood

Tube Type/Collection Container: Red top (no anticoagulant) tube

Collection Volume: 1.5 mL

Cause for rejection: -

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Immunoenzymatic Assay

Special Instructions: This test is not to be used for maternal screening. Days Performed: Mon-Fri 5 a.m. - 12 a.m. Saturday 6 a.m. - 6 p.m.

TAT: 1-3 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: < 6 ng/mL

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: