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. Hepatitis Acute Panel   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Hepatitis Acute Panel
CPT Code: 80074

Specimen Type: Blood

Tube Type/Collection Container: Gold top SST (serum separator tube,no anticoagulant)

Collection Volume: 6.5 mL (minimum 5.0 mL)

Cause for rejection: -

Storage: Frozen

Availability: Sent to reference lab

Methodology: Chemiluminescence Immunoassay (CLIA)

Special Instructions: If Hepatitis C Antibody is positive, a confirming test is suggested. If the Hepatitis B Surface Antigen is initially reactive, a confirming test will be performed at an additional cost.

TAT: 24 hours

Panel Includes: Hep Bs Ag; Hep B Core Ab, IgM; Hep A Ab, IgM; Hep C Ab


Lab/Phone: 330-543-8418

Additional Info: Reference range: Negative

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: