Alcohol
| 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. | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Specimen Type:
Blood
Tube Type:
Lt. Green/Mint-LiHep
Minimum Volume:
0.5 mL
Preferred Volume:
0.5 mL microtainer; 1.5 mL macrotainer
Storage:
Refrigerate
Special Instructions:
Do not use alcohol or chlorhexidine wipes to prepare venipuncture site. Soap and water or betadine may be used. Deliver specimen to lab immediately. If collected at an offsite location, send by a STAT Courier to Akron Children's Mahoning Valley Lab
Lab/Phone:
330-746-9623
TAT:
1 hour
CPT Code:
82077
Synonyms:
Ethanol, ETOH, Ethyl Alcohol
