Hemoglobin
| 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. Hemoglobin | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
HGB
Test Workstation :
MAHM1
Specimen Type:
Blood
Tube Type:
Purple top (EDTA) tube: Whole Blood
Collection Volume:
0.25 mL or 250 microliters minimum
Cause for Rejection:
Specimen hemolyzed, clotted, diluted with IV fluid; held at RT for more than 8 hours or at 4C for mor than 24 hours
Storage:
Refrigerated
Availability:
Daily, 24 hours; STAT
Methodology:
Flow Cell Spectrophotometry
Special Instructions:
Lipemic plasma or white count > 100,000/mm3 may falsely elevate the hemoglobin.
Lab/Phone:
330-746-9623
TAT:
4 hours
Additional Info:
Reference range is available on patient report
CPT Code:
85018
Synonyms:
HGB
