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. Bartonella PCR   
2.   
3.   
4.   
5.   
6.   

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

Specimen Type: Whole Blood

Tube Type/Collection Container: Lavender(EDTA)tube

Collection Volume: 3.0 mL Whole blood

Cause for rejection: -

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Real-time PCR

Special Instructions: Ship within 24 hrs This test does not differentiate between B. henslae and B. quintana. Bartonella Antibody Panel, IgG amd IgM should be considered for blood samples if PCR is negative and there is a strong suspicion of disease caused by these organisms. Days: Performed: Mon, Wed, Fri

TAT: 3-8 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: Negative

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: