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. GC Amplified Probe   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for GC Amplified Probe
CPT Code: 87591

Specimen Type: Cervical or Urethral Swab in BD-ProbeTec collection kit or first-void Urine

Tube Type/Collection Container: Specimen container

Collection Volume: One swab in BD-ProbeTec tube with at least 1.5 mL liquid, 20.0-60.0 mL urine(first-void, NOT midstream)

Cause for rejection: Swab: not in specific BD-Probe Tec tube, swab removed from tube, 2 swabs in one tube thereby soaking up liquid and making test QNS to run. Grossly bloody specimen. Urine: >60.0 mL decreases sensitivity of test

Storage: Refrigerated

Availability: Mon-Fri (0800-1700)

Methodology: Amplified DNA probe technique specific for Neisseria gonorrheae

Special Instructions: Test is FDA approved for genital or urine specimens only. DNA probe methodology only used at CHMCA for high prevalence populations. This method is not acceptable for forensic cases (e.g. rape or child abuse). Grossly bloody specimens may affect results. Obtain swab collection kits from CCL or Viro. Pink = female Blue = male Urine must be first void, not midstream; >60.0 mL will decrease sensitivity of the test.

TAT: 24-72 hrs


Lab/Phone: 330-543-8576

Additional Info: Positive results called and reported to ODH.

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: