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. Adenovirus Isolation   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Adenovirus Isolation
CPT Code: 87254

Specimen Type: NPH or throat or pharynx swab, nose, nasal wash, tracheal aspirate, sputum, bronchial aspirate or washings, conjunctiva.

Tube Type/Collection Container: Specimen container

Collection Volume: Fluids 1.0 mL, Swab specimen extracted into M4M transport medium

Cause for rejection: Specimen dry, not in proper M4M, not kept cold during transport, not received in sterile container, or excessive delay in transport.

Storage: Refrigerated

Availability: Daily (0800-1700)

Methodology: Spin-amplified svc w/ Adeno specific IFA stain

Special Instructions: Adenovirus associated with gastroenteritis (i.e. enteric types 40+41) will not be picked up by IFA.

TAT: 48-72 hours


Lab/Phone: 330-543-8576

Additional Info: Reference range: No Adenovirus isolated (Positives called)

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: