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. Human Metapneumovirus Isolation   
2.   
3.   
4.   
5.   
6.   

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

Specimen Type: Nasal washings, FLOCKED NPH swab

Tube Type/Collection Container: Specimen container

Collection Volume: Nasal wash: 1.5mL wash in viral transport medium (M4) Flocked NPH Swab: broken off into viral transport medium (M4)

Cause for rejection: Specimen not in viral transport medium (M4), specimen dry, in non-sterile container, or fixed in preservative, QNS

Storage: Refrigerated

Availability: Daily (0800-1700)

Methodology: Spin-amplified shell vial culture with monoclonal IFA

Special Instructions: NOTE: This test is included with all Respiratory Virus Isolation orders. Specimens in M4 must be sent on ice ASAP to lab. Positive results called. Final report issued at 72 hrs. Failure to isolate virus in culture does not rule out respiratory viral infection.

TAT: 3-4 days


Lab/Phone: 330-543-8576

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: