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. Enterovirus PCR   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Enterovirus PCR
CPT Code: 87498

Specimen Type: CSF, NPH flocked swab in M4, Plasma, Serum

Tube Type/Collection Container: CSF container, Purple top (EDTA)tube, Red top (no anticoagulant)tube

Collection Volume: 0.5 mL

Cause for rejection: Clotted CSF

Storage: Refrigerated

Availability: Mon-Fri

Methodology: Real-Time Polymerase Chain Reaction (PCR)

Special Instructions: Send fluids cold or on ice to lab immediately. Optimal specimen should not be frozen. If specimen has been frozen, it must be transported frozen. Specimens received by 1100 (Mon-Fri) will be processed the same day.

TAT: 1-3 days


Lab/Phone: 330-543-8722

Additional Info: Reference range: Qualitative

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: