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; The NPH swab broken off in M4 viral transport medium is also acceptable.

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: Negative: No Bordetella pertussis detected. Negative: No Bordetella parapertussis detected. NOTE: Cross-reactivity with Bordetella holmesii and some strains of Bordetella bronchiseptica may occur. Bordetella holmesii and Bordetella bronchiseptica infections are rare.

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: