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. Aerobe Culture   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Aerobe Culture
CPT Code: 87070

Specimen Type: Ear, eye, skin, cath tip, body fluid, dialysate, tissue

Tube Type/Collection Container: Eswab

Collection Volume: 1 swab or 0.5 mL fluid or 1 gram tissue

Cause for rejection: Specimen collected in nonsterile container. No swab sent in Eswab transport tube.

Storage: Ambient

Availability: Daily

Methodology: Culture

Special Instructions: Requisition or audit trail must specify site (e.g. right eye) of specimen along with important information regarding patient diagnosis (e.g. animal bite). If physician's orders state that the laboratory culture is for a specific organism, include this information on the requisition or audit trail. Deliver to laboratory immediately.

TAT: 72 hours


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: