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. Chloride, CSF   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Chloride, CSF
CPT Code: 82438

Specimen Type: CSF

Tube Type/Collection Container: CSF sterile container

Collection Volume: 1.0 mL (minimum 0.25 mL)

Cause for rejection: Gross hemolysis

Storage: Refrigerated

Availability: Sent to reference lab, MAYO

Methodology: Indirect Ion-Selective Electrode (ISE)

Special Instructions: Please order ZMSO send to Mayo

TAT: 1-2 days


Lab/Phone: 330-543-8417

Additional Info: Mayo Reference Range: 120-130 mmol/L

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: