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. EBV PCR, Qualitative   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for EBV PCR, Qualitative
CPT Code: 87798

Specimen Type: Plasma, CSF, BAL, or Bronch Wash

Tube Type/Collection Container: Purple top (EDTA) tube: Whole Blood, Specimen container

Collection Volume: 2.5 mL Blood, 0.5 mL CSF, BAL or Bronch Wash

Cause for rejection: QNS

Storage: Refrigerated

Availability: Batch testing Monday and Thursday

Methodology: Real-Time Polymerase Chain Reaction

Special Instructions: Centrifuge purple top tube promptly and send 1.0 mL (minimum 0.5 mL) plasma to the DNA lab, refrigerated.

TAT: 1-3 days


Lab/Phone: 330-543-8722

Additional Info: Reference Range: Negative: No EBV DNA detected.

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: