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. Toxoplasma PCR, Palo Alto   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Toxoplasma PCR, Palo Alto
CPT Code: 83890, 83896x2, 83898x2

Specimen Type: Amniotc Fluid, CSF,Vitreous fluid, Whole Blood, Bone Marrow, Urine or Solid Tissue

Tube Type/Collection Container: Sterile Container

Collection Volume: 10 mL

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Polymerase Chain Reaction (PCR)

Special Instructions: Specimen collected at greater than or equal to 18 weeks gestation. Specimens received by noon (PST) on Tuesday will have verbal results available Wednesday p.m. (PST). Specimens received by noon (PST) on Friday will have verbal results available by 4 p.m. (PST).

TAT: 2-4 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: Negative

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: