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. Blood Culture   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Blood Culture
CPT Code: 87040

Specimen Type: Blood

Tube Type/Collection Container: Blood culture bottle

Collection Volume: Click on "Blood culture" under the Specimen Collection Procedures link (below) for Table: Blood Culture Recommended Volume Based on Patient Weight

Cause for rejection: -

Storage: Ambient

Availability: Daily

Methodology: Automated Detection Instrumentation

Special Instructions: Blood cultures should be drawn prior to initiation of antimicrobial therapy. If more than one culture is drawn, the specimens should be drawn from different sites. The minimum amount of blood is only to be used in cases where there is a difficult draw. Do not overfill the bottles (>4mL in Pediatric or >10mL in adult aerobic and anaerobic bottles), as this can lead to false positives.

TAT: 5 days


Lab/Phone: 330-543-8412

Additional Info: Preliminary report available after 24 hours

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: