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. Influenza Isolation   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Influenza Isolation
CPT Code: 87254

Specimen Type: Throat/NPH swabs, nasal washings, sputum

Tube Type/Collection Container: Specimen container

Collection Volume: 1.5 mL specimen or inoculated M4M

Cause for rejection: Specimen dry, not in proper M4M, not refrigerated, not in sterile container, fixed in preservative, QNS

Storage: Refrigerated

Availability: Daily (0800-1700)

Methodology: Spin-amplified svc, 48 hr incubation and IFA stain with virus-specific monoclonal antibody

Special Instructions: This method does not detect any other viruses except Influenza A and B. A negative test does not rule out viral etiology.

TAT: 48-72 hrs.


Lab/Phone: 330-543-8576

Additional Info: Reference range: No influenza virus isolated

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: