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. CU Index   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for CU Index
CPT Code: 86352

Specimen Type: Blood

Tube Type/Collection Container: Red top ( no anticoagulant) tube

Collection Volume: 5.0 mL (minimum 1.5 mL)

Storage: Refrigerated

Availability: Days Performed Mon- Fri

Methodology: Ex Vivo Challenge, Cell Culture and Histamine Analysis

Special Instructions: Draw blood in a plain, red-top tube(s), allow clotting. Spin down and separate. Send 2 mL of serum refrigerated in a plastic vial. Note: Patients taking calcineurin inhibitors should stop medication 72 hours prior to draw. Patients taking predisone should be off their medication for 2 weeks prior to draw.

TAT: 2-3 days


Lab/Phone: 330-543-8417

Additional Info: Reference range: <10.0

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: