Fetal Fibronectin (SUMMA)

Centralized Core Laboratory - Summa Akron City Hospital : Send Out

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. Fetal Fibronectin (SUMMA)
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID :

FFN

Test Workstation :

SUMMA

Specimen Type:

Vaginal or Cervicovaginal

Tube Type:

Hologic FFN Collection Kit

Collection Volume:

0.2 mL

Minimum Volume:

0.1 mL

Cause for Rejection:

Specimen >3 days old, or not collected in Hologic FFN collection kit

Storage:

Refrigerated

Availability:

Sent to reference lab

Methodology:

Solid Phase Immunochromatographic Assay

Special Instructions:

Care must be taken not to contaminate the swab or cervicovaginal secretions with lubricants, soaps, disinfectants, or creams. Lubricants or creams may physically interfere with absorption of the specimen onto a swab. Soaps or disinfectants may interfere with the antibodyantigen reaction. Bloody or viscous specimens can cause interference with the testing method and result in an invalid result.

Lab/Phone:

330-543-8418

TAT:

1 Day

Additional Info:

Reference range: Negative or Positive

CPT Code:

82731