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. Adrenocorticotropic Hormone   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Adrenocorticotropic Hormone
CPT Code: 82024

Specimen Type: Plasma

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

Collection Volume: 2.5 mL (minimum 1.25 mL)

Storage: Frozen

Availability: Sent to reference lab

Methodology: Automated Chemilumininescent immunometric assay

Special Instructions: Spin down n a refrigerated centrifuge and immediately separate plasma from cells. Morning (6 a.m. -10:30 a.m.) specimen is desirable.

TAT: 1-2 days


Lab/Phone: 330-543-8418

Additional Info: Reference Range: 10-60 pg/mL (a.m. draws) No established reference range for p.m. draws.

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: