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. Hypersens. pneumonitis Panel   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Hypersens. pneumonitis Panel
CPT Code: 86331(x4) 86606 (x2)

Specimen Type: Blood

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

Collection Volume: 2.5 mL (minimum 1.25 mL)

Cause for rejection: -

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Immunodiffusion

Special Instructions: Remove serum from cells within 2 hours of collection.

TAT: 4-9 days

Panel Includes: Aspergillus funigatus #1; Aspergillus fumigatus #6; Aureobasidium pullulans; Pigeon serum; Micropolyspora faeni; Thermoactinomyces vulgaris #1


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: