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. Gamma-Hydroxybutyric Acid, Serum   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Gamma-Hydroxybutyric Acid, Serum
CPT Code: 82491

Specimen Type: Blood

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

Collection Volume: 10.0 mL (minimum 4.0 mL)

Cause for rejection: -

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Gas Chromatography/Flame Ionization Detection (GC-FID); Gas Chromatography/Mass Spectrometry (GCMS)

Special Instructions: Positive results will be confirmed by GCMS.

TAT: 6-8 days


Lab/Phone: 330-543-8418

Additional Info: The clinical efects of gamma-hydroxybutyric acid have been associated with the following concentrations: Wakefulness: <52 ug/mL Light sleep: 52-156 ug/mL Moderate sleep: 156-260 ug/mL Deep sleep: >260 ug/mL

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: