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. CSF Culture   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for CSF Culture
CPT Code: 87070

Specimen Type: Cerebrospinal fluid

Tube Type/Collection Container: CSF Container

Collection Volume: 1.0 mL (minimum 0.5 mL)

Cause for rejection: Specimen received in nonsterile container. Specimen sent on swab.

Storage: Ambient

Availability: Daily

Methodology: Culture

Special Instructions: Deliver to laboratory immediately. DO NOT PUT ON ICE! Be sure that caps are screwed on securely before transporting to laboratory. CSF culture includes cytoprep gram stain of specimen. Do not order a separate gram stain.

TAT: 72 hours


Lab/Phone: 330-746-9623

Additional Info: Preliminary report available after 24 hours

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: