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. KOH Preparation   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for KOH Preparation
CPT Code: 87220

Specimen Type: Skin, hair, nails, sputum, vaginal washing

Tube Type/Collection Container: Specimen container

Collection Volume: Small pieces of skin, nails or 1.0-2.0 mL of liquid specimen

Cause for rejection: Specimen sent on dry swab, QNS

Storage: Ambient

Availability: Daily (0800-1600)

Methodology: Microscopic exam

Special Instructions: Small petri dishes can be used to transport pieces of skin, hair, or nails to laboratory for examination. These petri dishes are available from Microbiology (38412) upon request. LIMITATION : Cultures are generally more sensitive than smears. The KOH preparation may be negative while the culture may be positive.

TAT: Same day


Lab/Phone: 330-543-8412

Additional Info: If received after 1600, prep will be read next day

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Ingrid Hershey, Laboratory Administrative Director, at 330-543-8721.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: