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. Mycoplasma pneumoniae PCR   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Mycoplasma pneumoniae PCR
CPT Code: 87581

Specimen Type: Throat swabs, sputum, bronch washes, trach aspirates, BAL, NPH-flocked swab, tissue, CSF

Tube Type/Collection Container: Specimen container

Collection Volume: 1.5 mL aspirate or inoculated M4M, 0.5g tissue, 1.0 cc CSF

Cause for rejection: Specimen dry, not in proper M4M, not refrigerated, not in sterile container, fixed in preservative, QNS

Storage: Refrigerated

Availability: Mon-Fri

Methodology: Real-Time Polymerase Chain Reaction (PCR)

Special Instructions: Send cold on ice. Deliver to lab ASAP. Break off swab into M4M promptly. Specimens received by 1100 will be processed the same day.

TAT: 1-3 days


Lab/Phone: 330-543-8722

Additional Info: Reference range: Qualitative

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: