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. Haemophilus influenzae Ag   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Haemophilus influenzae Ag
CPT Code: 87450

Specimen Type: CSF, Blood or Urine

Tube Type/Collection Container: Specimen container or Red top (no anticoagulant) tube

Collection Volume: 0.5 mL CSF / 1.0 mL serum / 5.0 mL urine

Cause for rejection: Serum with excessive hemolysis or lipemia may not be suitable for testing.

Storage: Refrigerated

Availability: Daily

Methodology: Antigen detection by latex agglutination

Special Instructions: Deliver to lab immediately. Urine specimens must be concentrated before testing and require a turnaround time of 2 hours. Urine specimens are processed 0730-1630.

TAT: 1-2 hours


Lab/Phone: 330-543-8412

Additional Info: -

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: