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. HIV-1 Genotype   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for HIV-1 Genotype
CPT Code: 87901

Specimen Type: Blood

Tube Type/Collection Container: Purple top (EDTA) tube

Collection Volume: 5.0 mL (minimum 1.5 mL)

Cause for rejection: -

Storage: Frozen

Availability: Sent to reference lab

Methodology: Reverse Transcription-Polymerase Chain Reaction (RT-PCR)/DNA Sequencing

Special Instructions: Centrifuge and separate plasma from cells within 6 hours of collection.

TAT: 2-10 days


Lab/Phone: 330-543-8418

Additional Info: Reference range is available on patient report Special Information: This test may be unsuccessful if the plasma HIV-1 RNA viral load is less than 1,000 HIV-1 RNA copies/mL plasma. If the viral load is ordered at the same time, the turnaround time for the HIV Genotyping will be delayed until the viral load is completed.

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: