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. CMV Isolation, Rapid   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for CMV Isolation, Rapid
CPT Code: 87254

Specimen Type: Urine, Bronchial washes, throat, CSF or Stool in M4M

Tube Type/Collection Container: Specimen container or swab

Collection Volume: 2.0 mL Urine (no preservative), 1.5 mL Bronch washing in M4M, Throat swab in M4M, 1.0 mL sterile CSF

Cause for rejection: Swabs dry, specimen fixed in preservative

Storage: Refrigerated

Availability: Mon-Fri (0800-1700)

Methodology: Spin-amplified svc with subsequent IFA stain

Special Instructions: Keep cold on ice or refrigerated. Deliver to lab ASAP. Use STERILE urine container or CSF tube. NO PRESERVATIVE. Test detects CMV only. See Virus Isolation for specific virus isolation for other suspected viruses. Specimens will be processed daily M-F if received in the Virology laboratory by 2:30 p.m. and on weekends if received by 11:30 a.m.

TAT: 24 hrs


Lab/Phone: 330-543-8576

Additional Info: Reference range: No CMV 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: