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. Rickettsia Antibodies, IgG & IgM   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Rickettsia Antibodies, IgG & IgM
CPT Code: 86757x4

Specimen Type: Blood

Tube Type/Collection Container: Gold top SST (serum separator tube, no anticoagulant)

Collection Volume: 3.0 mL (minimum 1.5 mL)

Cause for rejection: -

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Indirect Fluorescent Antibody (IFA)

Special Instructions: Remove serum from cells ASAP. Acute and convalescent specimens must be labeled as such; parallel testing is preferred and convalescent specimens MUST be received 30 days from receipt of the acute specimens. Please mark plainly as 'acute' or 'convalescent'. For Outpatients, test should only be drawn in outpatient locations within a Hospital (Akron or Beeghly).

TAT: 2-6 days

Panel Includes: R. typhi IgG, R. typhi IgM, R. rickettsi IgG, R. rickettsi 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 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: