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. EBV (VCA) IgG Ab   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for EBV (VCA) IgG Ab
CPT Code: 86665

Specimen Type: Blood

Tube Type/Collection Container: Red top (no anticoagulant) tube

Collection Volume: 3.0 mL (minimum 1.0 mL)

Cause for rejection: Excessively hemolyzed, lipemic or grossly contaminated specimen; drawn in incorrect tube; QNS

Storage: Refrigerated

Availability: Mon, Wed, Fri (0800-1700)

Methodology: Indirect Enzyme Immunoassay

Special Instructions: High EBV VCA IgG titers may persist for months. Test need not be done on patients with a pos Heterophile Ab. May be diagnostic in pediatric patients with Heterophile-neg Infectious Mononucleosis caused by Epstein-Barr virus. A 4-fold or greater increase in IgG titer strongly suggests recent or active infection.

TAT: 24-72 hrs


Lab/Phone: 330-543-8576

Additional Info: Reference range: < 0.90 = Neg; 0.91-1.09 = Equiv.; >/= 1.10 = Pos

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: