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. Iodine, Urine 24 Hr   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Iodine, Urine 24 Hr
CPT Code: 83789

Specimen Type: Urine

Tube Type/Collection Container: Urine container

Collection Volume: 10 mL urine from a well-mixed 24 hour collection

Cause for rejection: If Preservative was added.

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Inductively Coupled Plasma/Mass Spectrometry (ICP/MS)

Special Instructions: 10.0 mL (minimum 0.3 mL) urine aliquot from a well-mixed 24 hour urine collection in a plain preservative free container. Instruct patient on 24 hour urine collection. To begin the urine collection, have the patient void. DISCARD THIS URINE SPECIMEN. This is best done with the first morning specimen. Note the time and record on the requisition. From then on collect all the urine that is voided and place in container. If more than one container is needed, please mark the first as #1 of 2 and retain on the floor until the collection is complete. The final void should be made 24 hours after the first void described earlier. The specimen should be included with the collection. Refrigerate 24 hour urines during collection.

TAT: 2-6 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: Iodine Urine 24hr: 100-460 ug/24hrs Iodone Urine Random: 42-350 ug/L

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: