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. White Blood Cell Count   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for White Blood Cell Count
CPT Code: 85048

Specimen Type: Blood

Tube Type/Collection Container: Purple top (EDTA) tube: Whole Blood

Collection Volume: 2.0 mL (minimum 0.3 mL)

Cause for rejection: Specimen hemolyzed, clotted, diluted with IV fluid, or collected in heparin, specimen at room temperature >8hours or refrigerated specimens >24 hours.

Storage: Refrigerated

Availability: Daily, 24 hours; STAT

Methodology: Unopette and microscopic evaluation

Special Instructions: Indicate clearly if a specimen has been drawn from an arterial line or from a line that has been rinsed with heparin.

TAT: 8 hours


Lab/Phone: 330-543-8416

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 Ingrid Hershey, Laboratory Administrative Director, at 330-543-8721.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: