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. Virus Isolation   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Virus Isolation
CPT Code: 87252

Specimen Type: See specific virus culture

Tube Type/Collection Container: Specimen container

Collection Volume: See specific virus culture

Cause for rejection: More advanced methods with better report times are available if a specific virus isolation is requested.

Storage: See specific virus culture

Availability: Daily (0800-1700)

Methodology: Conventional tube culture on standard cell lines for the recognition of cytopathic effect (CPE) associated with specific viruses. Confirmed by IFA.

Special Instructions: Please order specific individual virus culture. Call Virology lab if Measles, Mumps or Rubella is suspected. Any requests for a generic Virus Isolation" must be written on a manual requisition and will be followed up with a call from the Virology lab."

TAT: NA


Lab/Phone: 330-543-8576

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: