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. Pinworm Prep   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Pinworm Prep
CPT Code: 87172

Specimen Type: Scotch tape slide preparation of perianal region or pinwormpaddle collection container

Tube Type/Collection Container: Pinworm paddle (preferred) or clear scotch tape on glass slide

Collection Volume: pinworm paddle (obtain from Microbiology ext 38412)

Cause for rejection: Opaque scotch tape

Storage: Ambient

Availability: Daily (0700-1630)

Methodology: Microscopy

Special Instructions: Specimen is best obtained a few hours after the patient has retired (2200 or 2300) or the first thing in the morning before patient has moved around. Pinworms migrate out of the anus during periods of rest and lay their eggs around the anal opening. This collection procedure is essential if valid results are expected. Clear Scotch Tape must be used if submitting specimens on slides.

TAT: 24 hours


Lab/Phone: 330-543-8412

Additional Info: Reference range: Negative for Enterobius vermicularis

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: