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. Bactericidal Level, Serum   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Bactericidal Level, Serum
CPT Code: 87197

Specimen Type: Blood

Tube Type/Collection Container: This assay requires multiple specimen types: Gold top SST (serum separator tube, no anticoagulant) Bacterial isolate on agar slant

Collection Volume: 1.0 mL (minimum 1.0 mL)

Cause for rejection: -

Storage: Serum- Frozen; Agar slant-Ambient

Availability: Sent to reference lab

Methodology: Macrotube titer

Special Instructions: In order to perform susceptibility testing to the drugs of choice and to interpret test results, the identification of the isolate is required. Provide current antibiotic therapy, date and time of last dose on test order. Physician must specify bacterial isolate to be tested within 72 hours of submission of specimen for culture. If the isolate has not been saved, the test cannot be performed.

TAT: 3-7 days


Lab/Phone: 330-543-8418

Additional Info: Reference range is available on patient report Days Performed: Mon-Fri

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: