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. Creat. Clearance 12 Hr   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Creat. Clearance 12 Hr
CPT Code: 82575

Specimen Type: Blood and Urine

Tube Type/Collection Container: Green top (lithium or sodium heparin) tube and Urine container

Collection Volume: 0.4 mL and 1.0 mL urine

Storage: Refrigerated

Availability: Daily (0800-1600)

Methodology: Enzymatic with Photometric Endpoint

Special Instructions: Instruct patient on 12 hour urine collection. Refrigerate 12 hour urines during collection. Do not use urine preservatives. Mark each container with patient information, including height and weight, and date and time collection started and finished. Deliver specimens promptly to lab.

TAT: 1 hour


Lab/Phone: 330-543-8417

Additional Info: Ref. range is age dependent; avail on patient report

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: