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. Cortisol Free, 24 HR, U   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Cortisol Free, 24 HR, U
Specimen Type: Urine

Tube Type/Collection Container: Urine-Container

Collection Volume: 5 mL Urine from a 24 HR Collection

Cause for rejection: If specimen isn't from a 24 HR Collection

Storage: Refrigerated

Availability: Mon- Fri & Sun 1 p.m.

Methodology: Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS)

Special Instructions: 1. Collect urine for 24 hours. 2. Add 10 g of boric acid as preservation at start of collection.

TAT: 2-5 days


Lab/Phone: 330-543-8414

Additional Info: 24- Hour volume is required

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: