Gestational 3HR Challenge

Centralized Core Laboratory - : Chemistry

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. Gestational 3HR Challenge
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID :

MG3HR

Test Workstation :

ACHM5

Specimen Type:

Blood

Tube Type:

Green top ( lithium heparin) tube

Minimum Volume:

500 uL

Preferred Volume:

1.5 mL

Storage:

Shipping- Send Refrigerated; Storage- Room Temp: 8 hours; Refrigerated: 72 hours; Frozen: 3 days

Availability:

Mon-Fri

Methodology:

Roche-UV Test

Special Instructions:

Separate plasma from cells ASAP. For outpatients, test should only be drawn in outpatient locations within a Hospital (Akron or Beeghly).

Lab/Phone:

330-543-8418

TAT:

1 hour/draw

CPT Code:

82951, 82952

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Gestational 3HR Challenge

Centralized Core Laboratory - : Chemistry

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