Department of Pathology
and Laboratory Medicine

Akron Children's Hospital
One Perkins Square
Akron, OH 44308
Laboratory
Ph: (330) 543-8573
Fax: (330) 543-3659

LABORATORY TEST REQUISITION


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. Arbovirus IgM, CSF   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Arbovirus IgM, CSF
CPT Code: 86651, 86652, 86653, 86654

Specimen Type: CSF

Tube Type/Collection Container: CSF Container

Collection Volume: 2.0 mL (minimum 1.0 mL)

Cause for rejection: -

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Indirect Fluorescent Antibody

Special Instructions: Aids in the diagnosis of suspected arboviral encephalitis. IgM class antibody is detectable within 1-3 weeks of onset, peaking and rapidly declining within 3 months.

TAT: 3-6 days

Panel Includes: St. Louis Encephalitis IgM, La Crosse Virus Encephalitis IgM, Western Equine Encephalitis IgM, Eastern Equine Encephalitis IgM


Lab/Phone: 330-543-8418

Additional Info: Reference range is available on patient report

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Ingrid Hershey, Laboratory Administrative Director, at 330-543-8721.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: