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. Lactate, WB   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Lactate, WB
CPT Code: 83605

Specimen Type: Blood

Tube Type/Collection Container: Heparinized syringe, Green top (lithium heparin) microtainer

Collection Volume: 0.5 mL microtainer or syringe; (2) 125 uL capillary tubes; If collected in a microtainer, it must be a separate tube with no gel separator

Cause for rejection: Clotted, air bubbles

Storage: Room Temp

Availability: Daily, 24 hours; STAT

Methodology: Ion selective electrode direct

Special Instructions: Deliver immediately to laboratory at room temperature. For Outpatients, test should only be drawn in outpatient locations within a Hospital (Akron or Beeghly). If collected at an offsite location, specimen is stable only 1 hour. Call a STAT Courier

TAT: 30 minutes


Lab/Phone: 330-543-8417

Additional Info: Reference range: 0.6-2.4 mmol/L

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: