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. Alcohol   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Alcohol
CPT Code: 80301

Specimen Type: Blood

Tube Type/Collection Container: Green top (lithium heparin) tube

Collection Volume: 0.4 mL (minimum 0.2 mL)

Cause for rejection: Gross lipemia

Storage: Refrigerated

Availability: Daily, 24 hours; STAT

Methodology: Enzymatic method with alcohol dehydrogenase

Special Instructions: Do not use alcohol wipes to prepare venipuncture site. Deliver specimen to lab immediately. Levels obtained are for medical use only; not intended for legal use. For Off-site locations, please draw specimen into a sodium fluoride vacutainer, and send by a STAT Courier to Akron Childrens at Mahoning Valley Hospital lab.

TAT: 1 hour


Lab/Phone: 330-746-9623

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: