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. Quantitative Culture   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Quantitative Culture
CPT Code: 87071

Specimen Type: Tissue

Tube Type/Collection Container: Specimen container

Collection Volume: 2.0 grams (minimum 0.5 grams)

Cause for rejection: Specimen collected in nonsterile container. Specimen to which formalin has been added cannot be used for culture.

Storage: Ambient

Availability: Daily (0800-1600)

Methodology: Culture

Special Instructions: Efforts should be made to collect the specimen early in the day since it must be processed by microbiology personnel before 1600. Requisition must state site from which the specimen was taken along with the time the specimen was collected.

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: