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. HSV PCR   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for HSV PCR
CPT Code: 87529

Specimen Type: CSF, wounds, lesion, body fluids, Plasm, Serum, NPH flocked swab, Nasal Wash, Bronch Wash, Trach aspirate, BAL, Amniotic fluid

Tube Type/Collection Container: Sterile container, lavender top(EDTA)tube, Red top (no anticoagunt)tube, or flocked swab in M4

Collection Volume: 0.5 mL

Cause for rejection: Clotted CSF; Fluids stored at ambient temperature, QNS

Storage: Refrigerated

Availability: Mon-Fri

Methodology: Real-Time Polymerase Chain Reaction (PCR)

Special Instructions: Send fluids cold or on ice to lab immediately. Bloody CSF's can inhibit PCR reaction. Specimens received by 1100 will be processed the same day.

TAT: 24-72 hrs


Lab/Phone: 330-543-8722

Additional Info: Reference range: Qualitative

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: