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. Helicobacter pylori IgM,G,A Abs   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Helicobacter pylori IgM,G,A Abs
CPT Code: 86677

Specimen Type: Blood

Tube Type/Collection Container: Gold top SST (serum separator tube, no anticoagulant)

Collection Volume: 3.0 mL (minimum 1.2 mL)

Cause for rejection: Plasma is not acceptable.

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Enzyme-Linked Immunosrbent assay (ELISA), Enzyme-Linked Fluorescence Assay (ELFA)

Special Instructions: H. pylori IgM and H.pylori IgA components are for research use only. Days Performed: Mon-Fri

TAT: 3-6 days

Panel Includes: H. pylori IgG, H. pylori IgM, H. pylori IgA


Lab/Phone: 330-543-8418

Additional Info: Reference range: IgG: <0.75 Index: Negative 0.75-0.99 Index: Equivocal >=1.00 Index: Positive IGM: <36.00 U/mL or <: Negative 36.00-40.00 U/mL: Equivocal >40.00 U/mL or >: Positive IgA: <18.00 U/mL or <: Negative 18.00-20.00 U/mL: Equivocal >20.00 U/mL or >: Positive

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: