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. Fibroblast Cult-Vir.   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Fibroblast Cult-Vir.
CPT Code: 88233

Specimen Type: Punch biopsy or autopsy of skin in HBSS, EMEM, or 0.9% NaCl

Tube Type/Collection Container: Specimen container

Collection Volume: Skin section 4 mm in diameter

Cause for rejection: Specimen dry, not in sterile container, QNS

Storage: Ambient

Availability: Daily (0800-1700)

Methodology: Tissue Culture for propagation of cells

Special Instructions: Fibroblast culture special requisition must accompany specimen. Specify freeze for storage only or specific tests requested. Please submit patient history and cover letter with name, address, phone # and contact person of reference lab. TAT for additional tests = additional 6 weeks - 6 mos. Sterile technique essential for non-contamination of specimen.

TAT: 6 weeks - 6 mos


Lab/Phone: 330-543-8576

Additional Info: Growth of cells depends largely on specimen quality.

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Ingrid Hershey, Laboratory Administrative Director, at 330-543-8721.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: