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. Gram Stain   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Gram Stain
CPT Code: 87205

Specimen Type: E-swab or smear from specimen for bacterial culture

Tube Type/Collection Container: Specimen container, E-swab

Collection Volume: 1 swab or 0.5 mL liquid specimen

Cause for rejection: Specimen sent in nonsterile container. Specimen sent on dry swab.

Storage: Ambient

Availability: Daily

Methodology: Microscopic examination

Special Instructions: Gram stain slides may be prepared at the bedside by the physician except for sputum, tracheal aspirate, wound, CSF, body fluids, or urine. Smears on these specimen types will be prepared in the laboratory. An E-swab should be sent for gram stain for those specimens where a swab is appropriate for culture.

TAT: 2 hours CSF, all other stains read by day shift Microbiology staff


Lab/Phone: 330-543-8412

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: