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 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: