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. Enterovirus Isol.   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Enterovirus Isol.
CPT Code: 87252

Specimen Type: Stool, Rectal, Throat, NPH swab, Lesions, Blood

Tube Type/Collection Container: Specimen container

Collection Volume: 1.0 mL CSF or 1.5 mL inoculated M4M

Cause for rejection: Specimen dry, not in proper M4M, not refrigerated, not in sterile container, fixed in preservative, QNS

Storage: Refrigerated

Availability: Daily (0800-1700)

Methodology: Spin-amplified svc, 48 hr incubation and monoclonal IFA stain. Back-up conventional tube culture.

Special Instructions: Send cold on ice. Deliver to the lab ASAP. Specimens will be processed daily M-F if received in the Virology laboratory by 2:30 p.m. and by 11:30 a.m. on weekends. Listing the source of the specimen is essential. M4M available from Viro lab or CCL. A negative result does not rule out viral etiology.

TAT: 2-10 days


Lab/Phone: 330-543-8576

Additional Info: Reference range: No Enterovirus isolated

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: