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. VRE Culture   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for VRE Culture
CPT Code: 87081

Specimen Type: Stool, Urine, G-tube site, Cath site

Tube Type/Collection Container: Specimen container, Eswab transport tube

Collection Volume: 0.5 mL (minimum - swab)

Cause for rejection: Specimen sent on dry swab. Specimen sent in nonsterile container, no swab in transport tube.

Storage: Ambient

Availability: Daily

Methodology: Culture

Special Instructions: These cultures are screened for Enterococcus sp. only! No other pathogens will be reported. Any Enterococcus isolated will be tested for sensitivity to Vancomycin. Orders must state specific site of specimen.

TAT: 48 hours


Lab/Phone: 330-543-8412

Additional Info: Preliminary report available after 24 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: