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. Ova & Parasites Scr   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Ova & Parasites Scr
CPT Code: 87328 X2

Specimen Type: Fresh Stool or Preserved Stool (Para-Pak formalin)

Tube Type/Collection Container: Stool container

Collection Volume: 10.0 mL (minimum 5.0 mL)

Cause for rejection: Stool specimen contaminated with urine or water. Specimen containing interfering substances such as barium. Specimen sent in a diaper.

Storage: Refrigerated

Availability: Daily Mon - Fri (0800-1600)

Methodology: Antigen Detection by Enzyme Immunoassay

Special Instructions: Test only screens for the presence of Giardia and Cryptosporidium antigen in stool. All stool specimens are preserved in 10% formalin and saved for 2 weeks. If the physician suspects parasitic infection other than Giardia or Cryptosporidium, call Microbiology (38412) and request Special Parasitology. (Sendout)

TAT: 24-72 hours


Lab/Phone: 330-543-8412

Additional Info: -

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: