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. Lyme Disease, Western Blot (Mayo)   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Lyme Disease, Western Blot (Mayo)
CPT Code: 86617x2

Specimen Type: Blood

Tube Type/Collection Container: Red top tube

Collection Volume: 2.5mL (minimum 0.8mL)

Cause for rejection: Hemolysis or lipemia

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Western Blot (WB)

Special Instructions: Draw blood in plain red top tube or serum gel tube. Heat-inactivated serum is not acceptable. Spin down and send 0.5mL serum refrigerated in screw-capped, round bottom, plastic vial. Forward promptly.

TAT: 3 days

Panel Includes: Lyme IgG W Blot, Lyme IgG Bands, Lyme IgM W Blot, Lyme IgM Bands, Lyme Western Blot Interpretation


Lab/Phone: 330-543-8148

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: