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, 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: Refrigerate Eswab if not sent to laboratory immediately. Do NOT refrigerate body fluids- send immediately to laboratory.

Availability: Daily

Methodology: Culture

Special Instructions: GC culture is for isolation of Neisseria gonorrhoeae only. Eswab supports growth of GC. Deliver to laboratory immediately.

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: