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. Fung Cult-Skin, Nail, Hair   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Fung Cult-Skin, Nail, Hair
CPT Code: 87101

Specimen Type: Skin, hair, nails

Tube Type/Collection Container: Specimen container

Collection Volume: Several small pieces of skin, hair, or nails

Cause for rejection: Specimen sent in nonsterile container, QNS - no specimen seen in container

Storage: Ambient

Availability: Daily

Methodology: Culture

Special Instructions: Small petri dishes can be used to transport pieces of skin, hair, or nails to laboratory for culture. These petri dishes are available from Microbiology (38412) upon request. Any sterile screw cap container is also available for transport of specimen. Deliver to lab immediately.

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: