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. Immune Function Assay ATP   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Immune Function Assay ATP
CPT Code: 8635382397

Specimen Type: Whole Blood

Tube Type/Collection Container: Green top (sodium heaprin) tube

Collection Volume: 4.5 mL

Cause for rejection: Sample must not be more than 30 hrs. old. Do not refrigerate.

Storage: Ambient

Availability: Sent to reference lab.

Methodology: Chemiluminescence (CL)

Special Instructions: Sample collection: Mon-Wed; and if collected on Thursday must be received in CHMCA lab by 11:00 AM on Thursday. Days Performed: Mon-Thur

TAT: 1-3 days


Lab/Phone: 330-543-8414

Additional Info: Reference range: ATP Level: 225-525 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: