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. Malaria Parasite Exam   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Malaria Parasite Exam
CPT Code: 87207

Specimen Type: Blood

Tube Type/Collection Container: Purple top (EDTA) tube: Whole Blood

Collection Volume: Four fingerstick slides, 2 thick and 2 thin blood smears

Cause for rejection: Improperly collected blood smears (thick smear preps are too thick, blood sloughs off upon drying).

Storage: Ambient

Availability: Daily (slide prep: 24 hours) Slide exam: 0700-1630

Methodology: Microscopic evaluation of Wright's stained blood film

Special Instructions: Smears should be made prior to febrile paroxysm. If fever is unpredictable, do fingerstick at the beginning of temperature rise.

TAT: 24 hours


Lab/Phone: 330-543-8416

Additional Info: Reference range: No organisms seen

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: