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. Pancreatic Enzyme Panel   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Pancreatic Enzyme Panel
CPT Code: 83519

Specimen Type: Duodenal Fluid

Tube Type/Collection Container: Fluid container

Collection Volume: 1.0 mL

Cause for rejection: -

Storage: Frozen

Availability: Sent to reference lab

Methodology: See individual tests

Special Instructions: Check pH of fluid to make sure the pH is 6.5 or higher.

TAT: 5 days

Panel Includes: pH, Trypsin, Amylase, Lipase, Chymotrypsin, Protein


Lab/Phone: 330-543-8418

Additional Info: Reference range is available on patient report

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Ingrid Hershey, Laboratory Administrative Director, at 330-543-8721.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: