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. Environment Culture   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Environment Culture
CPT Code: 87084

Specimen Type: Equipment swab, Formula, Water, Autoclave strips

Tube Type/Collection Container: Specimen container

Collection Volume: 5.0 mL fluid (minimum 1.0 mL or swab)

Cause for rejection: Specimen collected in nonsterile container

Storage: Refrigerated

Availability: Daily

Methodology: Culture

Special Instructions: Use Eswab to culture equipment. For fluid samples such as formula or dialysis water, please send at least 5.0 mL for testing. Deliver to laboratory as soon as possible.

TAT: 48 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: