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. Beta 2 Glycoproteins IgG, IgM, & IgA   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Beta 2 Glycoproteins IgG, IgM, & IgA
CPT Code: 86146 (x3)

Specimen Type: serum

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

Collection Volume: 1.5 mL(1.0 mL minimum)

Storage: Refrigerated

Availability: Sent to Reference Laboratory

Methodology: Enzyme-Linked Immunosorbent Assay (ELISA)

TAT: 1-6 days


Lab/Phone: 330-543-8418

Additional Info: Reference Range <10.0 U/mL (Negative) 10.0-14.9 U/mL (Borderline) > or =15.0 U/mL (Positive) Results are expressed in arbitrary units and apply to IgG, IgM, and IgA values. Reference values apply to all ages. Days Performed: Mon-Sat

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: