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. HIV RNA by PCR (Quantitative)   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for HIV RNA by PCR (Quantitative)
CPT Code: 87536

Specimen Type: Blood

Tube Type/Collection Container: Purple top (EDTA) tube

Collection Volume: 6.5 mL (minimum 3.0 mL)

Cause for rejection: -

Storage: Frozen

Availability: Sent to reference lab

Methodology: Polymerase Chain Reaction (PCR)

Special Instructions: This test is intended for use in conjunction with clinical presentation and as an indication of disease prognosis. This assay has a plasma HIV-1 RNA quantification result range from 20 to 10,000,000 copies/mL (1.30-7.00 log copies/mL)

TAT: 1-3 days


Lab/Phone: 330-543-8418

Additional Info: Reference range: Undetected

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: