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. EBV PCR, Quantitative   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for EBV PCR, Quantitative
CPT Code: 87799

Specimen Type: Plasma

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

Collection Volume: 0.5 mL plasma

Storage: Refrigerated

Availability: Tues, Fri

Methodology: Real-Time Polymerase Chain Reaction

TAT: 1-3 days


Lab/Phone: 330-543-8722

Additional Info: Reference Range: Negative; No EBV DNA Detected to >50,000,000 copies/mL

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: