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. Myco/Ureaplasma Cult   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Myco/Ureaplasma Cult
CPT Code: 87109

Specimen Type: Genital swabs, placenta, urine, amniotic fluid

Tube Type/Collection Container: Specimen container

Collection Volume: 1.5 mL aspirate or inoculated M4M

Cause for rejection: Specimen dry, fixed in preservative, or not in proper transport media

Storage: Refrigerated

Availability: Daily (0800-1700)

Methodology: Agar and broth cultures

Special Instructions: Deliver to lab immediately on ice. POP: keep cold, deliver ASAP. Organism remarkably sensitive to drying. Extract swab into M4M promptly. Urine specimens should be initial flow, not CCMS. Respiratory specimens from neonates are also acceptable. Mycoplasma, other than Ureaplasma urealyticum, when isolated, are reported as Myco. species and not identified further. Positive cultures are reported when detected.

TAT: 7-10 days


Lab/Phone: 330-543-8576

Additional Info: Reference range: No Mycoplasma or Ureaplasma isolated

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: