Herpes Simplex Virus (HSV) Type 1 and 2, Qualitative PCR

Molecular Diagnostics - : DNA

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. Herpes Simplex Virus (HSV) Type 1 and 2, Qualitative PCR
2.
3.
4.
5.
6.

SPECIMEN INFO

Collection Date & Time:

Collected By:

Hospital:

Test ID :

LAB917/HSVPC

Test Workstation :

DNA2

Specimen Type:

2 mL blood collected in one EDTA (purple top) tube.
2 mL whole blood collected in one no anticoagulant (red top) tube.
One flocked swab in 3.0 mL M4 Viral Transport Medium collected from lesion or respiratory source.
2.0 mL bronchoalveolar lavage (BAL), bronchial wash, nasal wash, or tracheal aspirate collected in sterile container.
0.5 mL amniotic or body fluids collected in sterile container.

Minimum Volume:

Whole blood and plasma minimum volume is 0.5 mL.
Amniotic or body fluids minimum volume is 0.2 mL.
BAL, bronchial wash, nasal wash, and tracheal aspirate minimum volume is 1.2 mL.

Cause for Rejection:

Quantity not sufficient, specimen clotted, improper anticoagulant, improper specimen type, improper storage/transport, improper swab, dry swab, swab not present in M4 VTM vial, multiple swabs per vial of M4 VTM, mislabeled, or unlabeled.

Storage:

Refrigerated

Availability:

Mon-Sat (7:30-16:00)

Methodology:

Real-time Polymerase Chain Reaction

Special Instructions:

For CSF specimens, order HSV PCR CSF (Test code HSDNA).

Lab/Phone:

330-543-8722

TAT:

1-3 days

CPT Code:

87529 x 2

Synonyms:

Herpes Simplex DNA; HSV DNA

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Herpes Simplex Virus (HSV) Type 1 and 2, Qualitative PCR

Molecular Diagnostics - : DNA

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