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 Ab Panel, CSF (IgG and IgM)   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Arbovirus Ab Panel, CSF (IgG and IgM)
CPT Code: 86651x2, 86652x2, 86653x2, 86654x2

Specimen Type: CSF

Tube Type/Collection Container: Sterile Container

Collection Volume: 0.5 mL (minimum 0.2 mL)

Storage: Refrigerated

Availability: Sent to Reference Laboratory

Methodology: Immunfluorescence Assay (IFA)

TAT: 1-4 days

Panel Includes: Lacrosse Enceph IgG LaCrosse Enceph IgM Eastern Eq Enceph IgG Eastern Eq Enceph IgM St. Louis Enceph IgG St. Louis Enceph IgM Western Eq Enceph IgG Western Eq Enceph IgM


Lab/Phone: 330-543-8418

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Cindy Maurer at (330)543-8689.

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


Physician Signature: Date: