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. Trichomonas Antigen   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Trichomonas Antigen
CPT Code: 87808

Specimen Type: Vaginal washing, or vaginal swab

Tube Type/Collection Container: Sterile container containing 1.0 mL sterile (nonbacterial) saline, or rayon swab in culturette

Collection Volume: 1.0 mL

Cause for rejection: Insufficient Specimen

Storage: Ambient <24hrs or Refrigerated (up to 36hrs)

Availability: Daily

Methodology: Immunochromatographic Assay

Special Instructions: Swabs from vagina are placed back in culturette or placed in sterile vial containing 1.0 mL sterile (nonbacteriostatic)saline. Swabs with cotton tips or wooden shafts are not recommended.

TAT: 1 hour


Lab/Phone: 330-746-9623

Additional Info: Validated for vaginal specimens.

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: