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 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: