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 gestational ages of 15-22 weeks. Testing Mon-Thurs preferred. A Children' Hospital Prenatal Screen Request Form (or a similar form from a prescribing 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 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: