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. Prenatal Quad Screen, CWRU   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Prenatal Quad Screen, CWRU
Specimen Type: Blood

Tube Type/Collection Container: Red top (no anticoagulant) or Gold top SST (serum separator, no anticoagulant) tube

Collection Volume: 7.0mL (minimum 5.0mL)

Cause for rejection: Specimen hemolyzed, gross lipemia, sample other than serum, specimen drawn after amniocentesis, gestational age <15 weeks or >= 23 weeks

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Two-site Flouroimmunometric, Time Result Fluoroimmuno Assay, Beckman Methodology

Special Instructions: Available for geatational ages of 15-22 weeks. Testing Mon-Thurs preferred. A Children' Hospital Prenatal Screen Request Form (or a similar form from a perscribing doctor) must be fully completed and sent with the specimen to the lab.

TAT: 1-3 days


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 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: