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. Respiratory Culture   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Respiratory Culture
CPT Code: 87070

Specimen Type: Throat, NPH, nose, sinus, bronchial aspirate or lavage

Tube Type/Collection Container: Specimen container, Eswab

Collection Volume: 0.5 mL (minimum-swab)

Cause for rejection: Specimen sent in nonsterile container. Specimen sent on dry swab, no swab in transport ube.

Storage: Ambient

Availability: Daily

Methodology: Culture

Special Instructions: Respiratory cultures include workup of all respiratory bacterial pathogens along with sensitivity testing. Cystic fibrosis patients must be designated as such on the requisition or audit trail accompanying the specimen. Throat cultures for Group A Strep only are not ordered under this test. SEE STREP CULTURE.

TAT: 48 hours


Lab/Phone: 330-543-8412

Additional Info: Preliminary report available after 24 hours

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: