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. Group B Strep Culture   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Group B Strep Culture
CPT Code: 87081

Specimen Type: Vaginal-rectal swab

Tube Type/Collection Container: Eswab

Storage: Ambient

Availability: Daily

Methodology: Culture

Special Instructions: Collect specimen from both areas and place in same Eswab transport tube to maximize recovery of Group B Strep.

TAT: 72 hours


Lab/Phone: 330-543-8412

Additional Info: Preliminary report available after 24 hours. Susceptibility performed on positive cultures to erythromycin and clindamycin upon physician request if patient is allergic to penicillins.

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: