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. Collagen Study, Fibr.   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Collagen Study, Fibr.
CPT Code: 88233

Specimen Type: Skin biopsy (4 mm punch)

Tube Type/Collection Container: Specimen container

Collection Volume: Skin section approximately 4mm in size

Cause for rejection: Skin section too small or to dry to grow, contaminated with bacteria or fungi or not received in liquid.

Storage: Ambient

Availability: Sent to reference lab

Methodology: Tissue culture technique for propagation of cells. Electrophoresis for collagen and procollagen assay.

Special Instructions: Store skin tissue in HBSS, EMEM, or 0.9% NaCl. Deliver ASAP. When fibroblasts are confluent, flasks are shipped to the University of Washington, Seattle, WA. This test is primarily used to rule out Osteogenesis Imperfecta (OI). Please submit patient history along with specific requestion for growth/storage of fibroblasts and any additional test requested. Available from the Virology lab.

TAT: 6 wks-6 mos


Lab/Phone: 330-543-8576

Additional Info: Ability to grow fibroblasts dependent on spec.size

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: