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. Fat, Feces (Qualitative and Quantitative)   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Fat, Feces (Qualitative and Quantitative)
CPT Code: 82710

Specimen Type: Stool

Tube Type/Collection Container: Stool container

Collection Volume: Qualitative: min 5 grams. Quantitative: Entire 24, 48 or 72 hour stool collection (send all stool); entire collection must contain at least 5 grams.

Cause for rejection: -

Storage: Frozen

Availability: Sent to reference lab

Methodology: Nuclear Magnetic Resonance (NMR) Spectroscopy

Special Instructions: For Qualitative requests, please indicate that stool is a RANDOM collection. For Quantitative requests (24, 48 or 72 hour stool), mark each container with patient information and date and time collection started and finished, and number of containers (ex., 1 of 4). For 3 days prior to and during the collection period: no barium, no laxatives, no synthetic fat substitutes or fat-blocking nutritional supplements. The use of diaper rash ointments will falsely elevate test results.

TAT: 2-8 days


Lab/Phone: 330-543-8418

Additional Info: Ref. range: > or = 18 years: 2-7 g/24 hrs Reference values have not been established for patients who are <18 years of age Random Collection: All ages: 0-19% fat

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: