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Methemoglobin

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. Methemoglobin
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

METHG MBG1

Specimen Type:

Blood

Tube Type:

Blood-Heparinized syringe, Green Top Tube, Capillary tubes or microtainer (lithium heparin) microtainer without gel

Collection Volume:

0.5 mL(minimum 250 uL)Green top(Lithium Heparin) Heparinized syringe, 2 capillary tubes or microtainer(lithium heparin)no gel

Cause for Rejection:

Clotted, air bubbles, tubes with gel separator.

Storage:

Room Temp

Availability:

Daily, 24 hours; STAT

Methodology:

Spectrophotometric measurement

Special Instructions:

Deliver immediately to laboratory at room temperature. For Outpatients, test should only be drawn in outpatient locations within the Hospital at the Beeghly campus. If collected at an offsite location, specimen is stable only 1 hour. Call a STAT Courier.

Lab/Phone:

330-746-9623

TAT:

30 minutes

Additional Info:

Reference range: 0.4 - 1.5 %

CPT Code:

83050

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