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. Anaerobe Culture   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Anaerobe Culture
CPT Code: 87075

Specimen Type: Sterile fluid (e.g. peritoneal), Wound, Abscess, Tissue

Tube Type/Collection Container: Eswab (1 Eswab can be used for both aerobe and anaerobe culture), or sterile specimen container

Collection Volume: Eswab / 1.0-2.0 mL fluid or pus

Cause for rejection: Specimen collected in nonsterile container. No swab in Eswab transport tube.

Storage: Ambient

Availability: Daily

Methodology: Culture

Special Instructions: An aerobic (routine) culture order should accompany any anaerobic culture order, since not all infections are caused by anaerobic bacteria. Do not order anaerobic cultures on specimens where anaerobic bacteria are normal flora such as vagina, throat, gastric, sputum, or bowel. Try to limit the specimens exposure to air. Order C. difficile by Amplification test on stool specimens for C. difficile toxin only.

TAT: 5 days


Lab/Phone: 330-543-8412

Additional Info: Preliminary report available after 48 hours

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: