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. Latex Profile   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Latex Profile
CPT Code: 86403x4

Specimen Type: CSF, Blood or Urine

Tube Type/Collection Container: Specimen container or Red top (no anticoagulant) tube

Collection Volume: 1.0 mL CSF / 2.0 mL serum / 5.0 mL urine

Cause for rejection: Serum with excessive hemolysis or lipemia may not be suitable for testing.

Storage: Refrigerated

Availability: Daily

Methodology: Antigen detection by latex agglutination

Special Instructions: The latex profile screens for antigens of Haemophilus influenzae type B, Neisseria meningitidis, Streptococcus pneumoniae, and Streptococcus group B. The presence of the antigen may indicate an infection by the organism. Group B Strep antigen is not available on urine specimens. (See Group B Strep Ag test for explanation).

TAT: 1-2 hours


Lab/Phone: 330-543-8412

Additional Info: -

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: