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:

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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

Specimen Type:

Blood (plasma)
Blood (serum)
Swab
Lesion
Conjunctiva
Bronchoalveolar lavage (BAL)
Wash
Tracheal Aspirate
Body Fluid
Synovial Fluid
Cerebrospinal Fluid (CSF)

Collection Volume:

Blood (plasma): 2 mL collected in a Purple Top- EDTA Tube (0.5 mL minimum)

Blood (serum): 2 mL collected in a Red Top Tube (0.5 mL minimum)

Swab, Lesion, or Conjunctiva: 1 Flocked Swab in 3.0 mL of M4 Viral Transport Medium

BAL, Wash, or Tracheal Aspirate: 2.0 mL collected in a Sterile Container (1.2 mL minimum)

Body Fluid or Synovial Fluid: 2.0 mL collected in a Sterile Container (0.2 mL minimum)

Cerebrospinal Fluid: 1.0 mL collected in a CSF Tube/Container (0.2 mL minimum)

Cause for Rejection:

Quantity Not Sufficient
Specimen Not Received
Specimen Mislabeled
Specimen Not Labeled
Broken/Spilled in Transport
Hemolyzed
Specimen Clotted
Unacceptable Type or Source Submitted
Wrong Container
Improperly Preserved/Processed
Sample Stored at Incorrect Temperature
Improper Swab
Multiple Swabs per Vial of M4 VTM
Swab Not Present in M4 VTM vial
Swab Not Placed in M4 VTM Vial (Dry Swab)
Sample Exceeds Holding Time

Storage:

Refrigerated

Availability:

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

Methodology:

Real-Time Polymerase Chain Reaction

Special Instructions:

Upon arrival in laboratory, promptly centrifuge blood specimen tube and send 1.0 mL of the plasma to the Molecular laboratory. Refrigerate.

For CSF specimens, order HSV PCR CSF

Lab/Phone:

330-543-8722

TAT:

1-3 days

CPT Code:

87529 x 2

Synonyms:

Herpes Simplex DNA; HSV DNA
HSV

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

Molecular Diagnostics - : DNA

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