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. Influenza Virus PCR   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Influenza Virus PCR
CPT Code: 87502

Specimen Type: Nasal Wash, NPH flocked swab

Tube Type/Collection Container: NPH flocked swab, NPH flocked swab in M4 Viral transport medium, or nasal wash fluid in sterile container

Collection Volume: 1 flocked swab, 0.5mL fluid

Cause for rejection: -

Storage: Refrigerated

Availability: Daily

Methodology: Polymerase Chain Reaction (PCR)

Special Instructions: Specimens received by 2:30 p.m. will be processed the same day.

TAT: 2-24 hours


Lab/Phone: 330-543-8722

Additional Info: Reference range: NEGATIVE. No Influenza RNA detected

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: