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. RSV PCR   
2.   
3.   
4.   
5.   
6.   

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

Specimen Type: NPH flocked swab, Nasal wash

Tube Type/Collection Container: NPH flocked swab, or fluid in sterile container

Collection Volume: 1 flocked swab, 0.5 mL fluid

Storage: Refrigerated

Availability: Daily

Methodology: Polymerase Chain Reaction (PCR)

Special Instructions: Sepcimens received by 2:30 P.M. will be processed the same day.


Lab/Phone: 330-543-8722

Additional Info: Reference range: Negative - No Respiratory Syncytial Virus (RSV) RNA 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: