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. Helicobacter Culture   
2.   
3.   
4.   
5.   
6.   

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

Specimen Type: Gastric mucosal biopsy; Stomach tissue

Tube Type/Collection Container: CLO Specimen container test slide

Collection Volume: Small tissue sample obtained by physician

Cause for rejection: Excessive delay in transporting to laboratory

Storage: Refrigerated

Availability: Daily

Methodology: Culture

Special Instructions: Gastric tissue is inserted into test slide by physician at bedside or in surgery. The laboratory will supply test slides to physician upon request. Transport CLO test slide to laboratory immediately. Unused test slides should be stored in refrigerator and allowed to warm to room temperature before use. DO NOT FREEZE TEST SLIDES!

TAT: 24 hours


Lab/Phone: 330-543-8412

Additional Info: -

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: