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. Body Fluid Cell Count and Differential   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Body Fluid Cell Count and Differential
CPT Code: 89051

Specimen Type: Cerebrospinal fluid; Body fluid

Tube Type/Collection Container: Fluid container

Collection Volume: 1.0 mL

Cause for rejection: Specimen more than 1 hour old, specimen grossly clotted

Storage: Ambient

Availability: Daily, 24 hour; STAT

Methodology: Hemocytometer count and microscopic evaluation of Wright's stained cytocentrifuge preparation

Special Instructions: Specify body fluid type

TAT: 1 hour


Lab/Phone: 330-543-8416

Additional Info: Reference ranges available under individual tests

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: