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. Streptococcus Pneumoniae IgG Ab, 7 Serotypes   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Streptococcus Pneumoniae IgG Ab, 7 Serotypes
CPT Code: 86317X7

Specimen Type: Blood

Tube Type/Collection Container: Gold top SST (Serum Separator tube, no anticoagulant)

Collection Volume: 1.5 mL (1.0 mL minimum)

Cause for rejection: Hemolysis, Lipemia, Icteric

Storage: Refrigerated

Availability: Sent to Reference Laboratory

Methodology: Microsphere Photometry

Special Instructions: Order this test if patient is < two years old. For patients 2 years and older please order LSPIGGAB23.

TAT: 3-6 days


Lab/Phone: 330-543-8418

Additional Info: Days Performed: Mon-Fri 8 AM Reference Range: Results are reported in ug/mL Serotype 4 (4) >1.9 Serotype 6B (26) >11.2 Serotype 9V (68) >2.8 Serotype 14 (14) >5.2 Serotype 18C (56) >2.7 Serotype 19F (19) >1.7 Serotype 23F (23) >2.9

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: