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. Poliovirus Types 1, 2, 3 Abs   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Poliovirus Types 1, 2, 3 Abs
CPT Code: 86658x3

Specimen Type: Blood

Tube Type/Collection Container: Red top (no anticoagulant) tube

Collection Volume: 2.5 mL (minimum 1.5 mL)

Cause for rejection: -

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Complement Fixation (CF)

Special Instructions: Documents exposure to Polio or other enteroviruses. For indication of immunity to Poliovirus (i.e. vaccine response) order Poliovirus Immune Status.

TAT: 2-12 days

Panel Includes: Poliovirus Type 1, 2, 3


Lab/Phone: 330-543-8418

Additional Info: Reference range: <1:8 <1:8 Antibody Not Detected > or = 1:8 Antibody Detected

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: