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. Bordetella pertussis/parapertussis PCR   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Bordetella pertussis/parapertussis PCR
CPT Code: 87798x2

Specimen Type: NPH flocked swab

Tube Type/Collection Container: 1 NPH swab in culturette or break off swab in M4 viral transport medium.

Cause for rejection: incorrect sample type

Storage: ambient or refrigerated

Availability: Mon-Fri

Methodology: Real-Time Polymerase Chain Reaction (PCR)

Special Instructions: Send to lab immediately. Specimens received by 1100 will be processed the same day

TAT: 1-3 days


Lab/Phone: 330-543-8722

Additional Info: Reference Range: Qualitative

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: