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. Helicobacter pylori Ag   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Helicobacter pylori Ag
CPT Code: 87338

Specimen Type: Stool

Tube Type/Collection Container: Stool container

Collection Volume: 5.0 grams (minimum 1.0 gram)

Cause for rejection: Stool specimen sent on swab, diaper, or dried on an applicator stick. Stool sent in viral transport media.

Storage: Refrigerated

Availability: Daily (0800-1600)

Methodology: Antigen Detection by Immunochromatographic Assay

Special Instructions: Deliver to laboratory as soon as possible. Stool specimens received on before 1200 will be run that same day. Specimens received in the afternoon will be put on the next run of patient specimens.

TAT: 48 hours


Lab/Phone: 330-543-8412

Additional Info: -

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: