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. West Nile Virus CSF IgG & IgM   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for West Nile Virus CSF IgG & IgM
CPT Code: 86788, 86789

Specimen Type: CSF

Tube Type/Collection Container: CSF container

Collection Volume: 0.5 mL (minimum 0.1 mL)

Cause for rejection: -

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Enzyme-Linked Immunosorbent Assay (ELISA)

Special Instructions: In acute infection, specific antibodies are sometimes detectable in CSF before they are detectable in serum. Interpretation of results may be complicated by low antibody levels found in CSF, passive transfer of antibody from blood, and contamination via bloody taps.

TAT: 4-7 days

Panel Includes: West Nile Virus IgG, West Nile Virus IgM


Lab/Phone: 330-543-8576

Additional Info: Reference range: IgG < 1.30; IgM < 0.90 Index Units

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: