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. If patient is symptomatic, find out if patient has visited foreign countries recently, has a headache, nausea, fever, chills or is vomiting.

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: