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. Fetal Fibronectin (AGMC)   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Fetal Fibronectin (AGMC)
CPT Code: 82731

Specimen Type: Vaginal Swab

Tube Type/Collection Container: Specimen Transport Tube

Collection Volume: 0.2 mL (minimum 0.1 mL)

Cause for rejection: -

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Immunochromatographic Assay

Special Instructions: Care must be taken not to contaminate the swab or cervicovaginal secretions with lubricants, soaps, disinfectants, or creams. Lubricants or creams may physically interfere with absorption of the specimen onto the swab. Soaps or disinfectants may interfere with the antibody-antigen reaction.

TAT: 1 Day


Lab/Phone: 330-543-8418

Additional Info: Reference range: Negative or Positive

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: