VWF GPIbM Activity

Centralized Core Laboratory : Hematology

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. VWF GPIbM Activity
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID/Workstation :

GPIBM BCOWI

Specimen Type:

Blood

Tube Type:

Blue top ( sodium citrate)tube

Collection Volume:

2.7 mL

Storage:

Frozen

Methodology:

ELISA

Special Instructions:

If collected at an offsite location, send by STAT courier to Akron Children's Hospital Laboratory.

Lab/Phone:

330-543-8418

TAT:

7 days

Additional Info:

Reference range: 52-180 IU/dL

CPT Code:

85397

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