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. Vibrio Culture   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Vibrio Culture
CPT Code: 87046

Specimen Type: Fresh whole stool, Rectal swab

Tube Type/Collection Container: Stool container or rectal swab in Eswab transport tube

Collection Volume: Whole stool (minimum - swab)

Cause for rejection: Specimen contaminated with urine or water. Stool containing barium. Specimen sent to laboratory in diaper, or on wooden stick/tongue depressor; no swab in Eswab transport tube.

Storage: Ambient

Availability: Daily

Methodology: Culture

Special Instructions: Send whole fresh stool if possible. Rectal swab may be taken if patient cannot produce stool. If physician orders stool screened for Vibrio, order Vibrio culture separately and in addition to Enteric culture.

TAT: 72 hours


Lab/Phone: 330-543-8412

Additional Info: Preliminary report available after 24 hours

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: