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. Phenytoin   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Phenytoin
CPT Code: 80185

Specimen Type: Blood

Tube Type/Collection Container: Green top (lithium heparin) tube

Collection Volume: 0.4 mL

Cause for rejection: -

Storage: Frozen

Availability: Daily, 24 hours; STAT

Methodology: Enhanced Turbidimetric Inhibition Immunoassay

Special Instructions: For therapeutic monitoring, draw peak levels 2-4 hours post-IV infusion(loading dose) or 3-9 hours post-oral ingestion and trough levels immediately prior to next dose. Please indicate whether the specimen is a peak, trough, or random specimen.

TAT: 1 hour


Lab/Phone: 330-543-8417

Additional Info: Therapeutic range: 10.0-20.0 ug/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: