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. VZV Isolation   
2.   
3.   
4.   
5.   
6.   

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

Specimen Type: Swabs of fresh, unroofed lesions, vesicle fluid or scrapings

Tube Type/Collection Container: Specimen container

Collection Volume: 1.5 mL washings, aspirate, or inoculated M4M

Cause for rejection: Specimen dry, not in proper M4M, not refrigerated, not in sterile container, fixed in preservative, QNS

Storage: Refrigerated

Availability: Daily (0800-1700)

Methodology: Spin-amplified svc and IFA stain specific for VZV after 72 hr incubation

Special Instructions: Add fluid from several vesicles or scrapings from several lesions to M4M. (Available from CCL or Viro.). Send to lab immediately on ice. DO NOT FREEZE. VZV is very labile and often does not grow if transported under adverse conditions. Specimens will be processed daily M-F if received in the Virology laboratory by 2:30 p.m. and by 11:30 a.m. on weekends

TAT: 72 hrs


Lab/Phone: 330-543-8576

Additional Info: Reference range: No VZV isolated

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: