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. Wright's Stain   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Wright's Stain
CPT Code: 87205

Specimen Type: Stool

Tube Type/Collection Container: Stool container, Rectal swab in culturette(See Special Instructions)

Collection Volume: 1.0 mL

Cause for rejection: Stool contaminated with urine, water, or interfering substances such as barium. Stool specimen sent on dry swab. Specimens sent in a diaper.

Storage: Refrigerated

Availability: Daily ( Slides are read on dayshift only 0800-1600)

Methodology: Microscopic examination

Special Instructions: Fresh stool is the optimal specimen for examination. WBC's will be destroyed as specimen is allowed to age. If a rectal swab is collected, the Wright Stain is the only test that can be done due to contamination when the smear is prepared in the laboratory.

TAT: 2-16 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: