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. Platelet Function Test   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Platelet Function Test
CPT Code: 85576

Specimen Type: Blood

Tube Type/Collection Container: Blue top (sodium citrate) tube

Collection Volume: 2.7 mL

Cause for rejection: Sample hemolyzed, clotted, diluted with IV fluid; contaminated with heparin; improperly filled; received on ice; received > 4 hrs after drawn

Storage: Ambient

Availability: Daily, 24 hours

Methodology: Test Cartridge System Simulating Platelet Adhesion and Aggregation

Special Instructions: Specimens should be sent to the lab immediately. Specimens should not be sent on ice. Call STAT courier if collected off-site

TAT: 1 hour

Panel Includes: Collagen/Ephinephrine, Collagen/ADP


Lab/Phone: 330-543-8416

Additional Info: Reference range: COL/EPI = 80-184 sec COL/ADP = 56-102 sec NOTE: Platelet counts less than 50,000 will not give accurate results and may be rejected.

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: