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

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Adenovirus Ag Stain
CPT Code: 87260

Specimen Type: Nasal Washings, or 2 FLOCKED NPH swabs, or Tracheal aspirate

Tube Type/Collection Container: Specimen container

Collection Volume: 1.5 mL wash or aspirate in sterile container plus 0.5 mL wash or aspirate in viral transport medium (M4) OR 2 Flocked NPH swabs: send one swab in culturette and one swab broken off into viral transport medium (M4)

Cause for rejection: Specimen dry, non-sterile container or incorrect swab ( do not use NPH wire swab), QNS, or no portion of specimen in M4 medium for back-up Respiratory Virus Isolation.

Storage: Refrigerated

Availability: Daily (0800-1700)

Methodology: DFA

Special Instructions: Specimens in M4 must be sent on ice ASAP to lab. Specimens MUST contain respiratory epithelial cells. Nasal wash or NPH swab in culturette used for Direct Antigen Stain. Same day results if specimen is received Mon- Fri. by 1430, Sat/Sun- by 1100. Nasal wash in M4 or NPH swab in M4 used for Respiratory Virus Isolation if rapid is negative or contains insufficient respiratory cells for direct stain. A negative result does not rule out viral infection. Positive results will be called.

TAT: 2 hours


Lab/Phone: 330-543-8576

Additional Info: Reference range: Adenovirus Ag: Negative

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: