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. Chlamydia Culture   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Chlamydia Culture
CPT Code: 87110

Specimen Type: Eye (conjunctiva), Flocked NPH swab, Throat, Genital or Rectal swabs, Tissue and aspirates added to Viral Transport Medium (M4) acceptable.

Tube Type/Collection Container: Specimen container

Collection Volume: Swab extracted or broken off into viral transport medium (M4)

Cause for rejection: Specimen not in viral transport medium (M4), dry, in non-sterile container, QNS

Storage: Refrigerated

Availability: Mon, Wed, Fri

Methodology: Spin-amplified shell vial culture with subsequent IFA stain to confirm

Special Instructions: Specimens in M4 must be sent on ice immediately to lab. Viral transport medium (M4) available from Virology (ext. 38576) or CCL ( ext. 38417) labs. Urine specimens are NOT acceptable. A negative result does not rule out infection. Positive results called.

TAT: 2-5 days


Lab/Phone: 330-543-8576

Additional Info: Reference Range: NEGATIVE. No Chlamydia isolated.

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: