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. VZV Ag Stain   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for VZV Ag Stain
CPT Code: 87290

Specimen Type: Basal cells from scraped lesions smeared onto a 3-well slide. Collect second swab specimen in M4 viral transport medium for VZV isolation backup

Tube Type/Collection Container: Specimen container

Collection Volume: (1) 3-well teflon slide; Each well amply coated with cells.

Cause for rejection: Insufficient quantity of specimen on slide or poorly made slide

Storage: Ambient

Availability: Daily (0800-1700)

Methodology: DFA stain specific for VZV antigen

Special Instructions: Obtain 3-well slide and holder (to prevent breakage in the TTS) from Virology. Label slide with patient identification. Send to lab immediately. DO NOT STORE. Same day results if slides received by 1500 (Mon-Fri) or 1100 (Sat and Sun). This is the test of choice for detection of VZV Antigen if slides are of good quality. STAT: Call 330-543-8576. Send second swab specimen in M4 viral transport medium for backup culture (see VZV Isolation)

TAT: 24 hrs


Lab/Phone: 330-543-8576

Additional Info: Reference range: No VZV antigen detected

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: