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. Ova and Parasite Special Exam   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Ova and Parasite Special Exam
CPT Code: 87177

Specimen Type: Stool

Tube Type/Collection Container: Stool container

Collection Volume: 10.0 mL (minimum 5.0 mL)

Cause for rejection: Stool specimen contaminated with urine or water. Specimen containing interfering substances such as barium. Specimen sent in a diaper. Rectal swab not acceptable.

Storage: Refrigerated

Availability: Sent to Reference Laboratory

Methodology: Microscopic examination

Special Instructions: Fresh stool is the optimal specimen for examination. Order Ova and Parasite Screen (OPSCR) with all OPEXM orders. WARNING: Any stool collected by or from the patient may harbor pathogens which are immediately infective.

TAT: 2-4 days


Lab/Phone: 330-543-8412

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: