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 a sterile rayon swab from the kit. Use of BD BBL CultureSwab (sterile or with Liquid Stuart's Media) is recommended. Swabs from other suppliers have not been validated and will be rejected.

Collection Volume: 1.0 mL

Cause for rejection: Insufficient Specimen; Eswab, Swabs with cotton tips, or wooden shafts are not acceptable. Urine specimens are NOT an acceptable specimen for the Trichomonas Antigen test.

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.

TAT: 1 hour


Lab/Phone: 330-543-8412

Additional Info: - Validated for vaginal specimens.

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Ingrid Hershey, Laboratory Administrative Director, at 330-543-8721.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: