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. HSV Ag Stain   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for HSV Ag Stain
CPT Code: 87274

Specimen Type: Basal cells from a freshly unroofed lesion

Tube Type/Collection Container: Specimen container

Collection Volume: (1) 3-WELL (EACH AMPLY COATED WITH CELLS) TEFLON SLIDE

Cause for rejection: Slide poorly prepared or containing insufficient cells

Storage: Ambient

Availability: Daily (0800-1700)

Methodology: Direct Fluorescent Antibody (DFA) staining of collected cells

Special Instructions: Cells from mucocutaneous lesions should be obtained by swabbing base of lesion and transferring cells to all three wells of special slide obtain from Viro). Collect specimen in M4M for culture at same time. Label specimens (including slide) properly. Send to lab immediately. Same day results if received by 1500.

TAT: 24 hrs


Lab/Phone: 330-543-8576

Additional Info: Reference range: Negative for HSV

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: