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. Eosinophil Stain   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Eosinophil Stain
CPT Code: 89190

Specimen Type: Nasal secretion, stool

Tube Type/Collection Container: Specimen container

Collection Volume: 1 smear or slide

Cause for rejection: Slides received with no visible specimen. Slides received in cytology fixative.

Storage: Ambient

Availability: Daily (0800-1600)

Methodology: Microscopic examination

Special Instructions: Nasal smears are usually prepared at bedside or in Dr.'s office. Secretions are collected by having patient blow nose on waxed paper or cellophane. The specimen should then be smeared on a clean microscope slide. Allow smear to dry and place another slide over top with toothpicks in between. Send stool to laboratory ASAP for slide preparation.

TAT: 2 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: