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. FK506   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for FK506
CPT Code: 80197

Specimen Type: Blood

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

Collection Volume: 2.0 mL

Cause for rejection: Clotted Specimen

Storage: Refrigerated

Availability: Daily

Methodology: Enzyme Immunoassay ( EIA )

Special Instructions: Specimens in lab by 12:00, instrument run at 13:00, results by 16:00. Reguardless of tube size, the tube must be 1/3 full.

TAT: 4 hours


Lab/Phone: 330-543-8418

Additional Info: Reference range: 5.0-20.0 ng/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: