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. ANA Ab w/Reflex   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for ANA Ab w/Reflex
CPT Code: 86038

Specimen Type: Blood

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

Collection Volume: 3.0 mL (minimum 2.0 mL)

Cause for rejection: -

Storage: Ambient, refrigerated, or frozen

Availability: Mon, Wed, Fri

Methodology: Enzyme Immunoassay

Special Instructions: If ANA Ab by IFA is positive, then the specimen is reflexed to include ANA titer and pattern, ENA1, ENA2 and n-DNA Ab.

TAT: 48 hours


Lab/Phone: 330-543-8576

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 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: