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. Cystatin C   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Cystatin C
CPT Code: 82610

Specimen Type: Blood

Tube Type/Collection Container: Red top (no anticoagulant)

Collection Volume: 2.5mL (minimum 1.5mL)

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Immunoturbidimetric

Special Instructions: See patient results for Reference Ranges. Reference range values have not been established for patients that are <23 years of age. Estimated GFR will not be calculated for patients under 18 years.

Panel Includes: Cystatin C, Serum Estimated Glomerular Filtration Rate (eGFR) by Cystatin C


Lab/Phone: 330-543-8418

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: