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. Drugs of Abuse - Urine   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Drugs of Abuse - Urine
CPT Code: 80101

Specimen Type: Urine

Tube Type/Collection Container: Urine Container

Collection Volume: 20 mL

Storage: Refrigerated

Availability: Sent to Reference lab

TAT: 4 hrs

Panel Includes: Amphetamines, Barbiturates, Benzodiazepines, Cannabinoids, Cocaine Metabolite, Methadone, Opiates, Phencyclidine, Propoxyphene


Lab/Phone: 330-746-9623

Additional Info: Reference range: Amphetamines: Not Detected Cutoff: 1000 ng/mL Barbiturates: Not Detected Cutoff: 200 ng/mL Benzodiazepines: Not Detected Cutoff: 200 ng/mL Cannabinoids: Not Detected Cutoff: 50 ng/mL Cocaine Metabolites: Not Detected Cutoff: 300 ng/mL Methadone: Not Detected Cutoff: 300 ng/mL Opiates: Not Detected Cutoff: 300 ng/mL Phencyclidine: Not Detected Cutoff: 25 ng/mL Propoxyphene: Not Detected Cutoff: 300 nhg/mL

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: