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. Fungus Culture, Blood   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Fungus Culture, Blood
CPT Code: 87103

Specimen Type: Blood

Tube Type/Collection Container: Culture bottles

Collection Volume: 10.0 mL purple or green (minimum 5.0 mL), 4.0 mL yellow (minimum 1.0 mL/bottle)

Cause for rejection: -

Storage: Ambient

Availability: Daily

Methodology: Automated Detection Instrumentation

Special Instructions: Orders must state blood culture is for fungal isolation. A single blood culture can be cultured for bacteria as well as fungus. Contact Microbiology (38412) if a fungal culture is ordered on a blood already in progress in the laboratory.

TAT: 14 days


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: