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. HSV Isolation/Typing   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for HSV Isolation/Typing
CPT Code: 87252

Specimen Type: Skin, lip, genital, conjunctiva, throat, NPH swabs/aspirates, stool or stool swab in M4

Tube Type/Collection Container: Flocked swab in M4M

Collection Volume: 1.5 mL aspirate or inoculated viral transport media (M4M)

Cause for rejection: Specimen dry, fixed in preservative or not in proper viral transport media

Storage: Refrigerated

Availability: Daily (0800-1700)

Methodology: Enzyme Linked Virus Inducible System (ELVIS-tm) svc. Typing by IFA

Special Instructions: Swab patient site with enough force to obtain epithelial cells. Conjunctiva - use moistened swab. Break off swabs into M4M (viral transport media). M4M is available from Micro/Viro lab and CCL. Specimens will be processed daily M-F if received in the laboratory by 2:30 p.m. and on weekends if received by 11:30 a.m.

TAT: 24 hours


Lab/Phone: 330-543-8576

Additional Info: Reference range: No HSV 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: