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. Parasite ID, Macroscopic   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Parasite ID, Macroscopic
CPT Code: 87169

Specimen Type: Gastric aspirate, tick, Worm for ID

Tube Type/Collection Container: Specimen container

Collection Volume: 5.0(minimum 1.0)

Cause for rejection: QNS

Storage: Refrigerated

Availability: Daily

Methodology: Parasite examination, Macroscopic

Special Instructions: Send gastric/duodenal aspirate to laboratory ASAP. Tick or worm ID may require consultation with Medical Director. For ID to the genus and species level, ticks are sent to the Ohio Department of Health Vector-Borne Disease Unit.

TAT: 48-72 hours


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: