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. GC Culture   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for GC Culture
CPT Code: 87081

Specimen Type: Vagina, cervix, urethra, eye, urine, joint or body fluid

Tube Type/Collection Container: ESwab

Collection Volume: Inoculated swab, 0.5 mL urine minimum

Cause for rejection: No swab in transport tube.

Storage: Swab: refrigerated if not sent to laboratory immediately Urine/Body fluid: Do NOT refrigerate send to laboratory STAT

Availability: Daily

Methodology: Culture

Special Instructions: GC culture is for isolation of Neisseria gonorrhoeae only. Eswab supports growth of GC. Urine specimen must be sent to laboratory for processing. Deliver to laboratory immediately. Do not refrigerate urine. Order GC culture on urine.

TAT: 72 hours


Lab/Phone: 330-543-8412

Additional Info: Preliminary report available after 24 hours

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: