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. Glucose by Meter   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Glucose by Meter
CPT Code: 82948

Specimen Type: Fresh Whole Peripheral Blood

Tube Type/Collection Container: None

Collection Volume: 1 drop by capillary puncture at patient's bedside

Cause for rejection: -

Storage: None

Availability: Daily, 24 hours; STAT

Methodology: Electrochemical principle of Biamperometry

Special Instructions: Heparinized whole blood can also be sent to lab if capillary puncture is not possible (ex: burned extremities or patient has a line to avoid repeated punctures). Glucose by meter levels that are <45 mg/dL or >450 mg/dL (>300 mg/dL for NICU patients) will be confirmed via a whole blood specimen analyzed on the EML.

TAT: 20 minutes


Lab/Phone: 330-543-8418

Additional Info: Reference range: 60-110 mg/dL; 30-90 mg/dL (Neonate)

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: