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. Methotrexate   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Methotrexate
CPT Code: 80299

Specimen Type: Blood

Tube Type/Collection Container: Green top (lithium) plasma

Collection Volume: 3.0 mL (minimum 0.2 mL)

Storage: Refrigerated

Availability: Daily, 24 hours

Methodology: Fluorescence Polarization Immunoassay

Special Instructions: Specimen must be protected from light Specimen must be frozen if not analyzed within 24 hours.

TAT: 4 hours


Lab/Phone: 330-543-8418

Additional Info: Reference range: Following a 4-6 hour infusion a patient with a 24 hr serum concentration of >5-10 umol/L, a 48 hr level of > 0.5-1.0 umol/L or a 72 hr level >0.2 umol/L is at increased risk for toxicity if conventional low dose leucovorin rescue is given.

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: