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. Fungal Culture   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Fungal Culture
CPT Code: 87102

Specimen Type: Urine, stool, vagina, respiratory specimens, tissue, fluids

Tube Type/Collection Container: Specimen container

Collection Volume: 1.0 mL fluid or 0.5 grams of tissue

Cause for rejection: Specimen sent in nonsterile container.

Storage: Ambient

Availability: Daily

Methodology: Culture

Special Instructions: Tissue or body fluid is optimal for isolation of fungi. Use E-Swab for specimens submitted from sites such as throat or vaginal, or when adequate tissue or fluid is not available.

TAT: 6 weeks


Lab/Phone: 330-543-8412

Additional Info: Preliminary report available after 72 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: