Requestor (s) Patient Central Zone Laboratory Requisition PHN Alternate Identifier Last Name First Name Address City/Town Accession # Date of Birth Middle Prov (lab only) (yyyy-Mon-dd) Gender M F Postal Code Phone Location Requestor Name Copy to Copy to (last, first) (last, first) (last, first) Location/Facility/Address Location/Facility/Address Location/Facility/Address Phone Phone Phone Healthcare Provider ID Healthcare Provider ID Healthcare Provider ID Collection Date (yyyy-Mon-dd) Priority: Routine Stat Time Urgent Location (24 hr) Timed F Collector ID Denotes a Fasting Test. Refer to Patient instruction Sheet. Hematology/Coagulation Urine (Random/24 h/Timed) Transfusion Medicine CBC (Includes Differential) D-dimer Prothrombin Time/INR Fibrinogen Reticulocyte Count Creatinine Clearance, 24 h HCG, Qualitative (pregnancy urine) Microalbumin, Timed/24 h Microalbumin/Creatinine Ratio, Random Protein/Creatinine Ratio, Random Protein Electrophoresis: Random 24 h Total Protein: Random 24 h Urinalysis Required for 24 Hr Urine Volume ___________ Height (cm) ________ Weight (kg) ________ Start Date/Time ___________ / ___________ End Date/Time ___________ / ___________ Blood Type RHIG Prophylaxis Direct Antiglobulin Test Type and Screen Crossmatch (Number of Units): _____________ Date/Time Required __________ / ____________ Method of Transport ________________________ Reason for Request: ________________________ Previous transfusion: Yes No Date ____________________ Previous pregnancy: Yes No Date ____________________ Previously detected antibodies: _______________ ________________________________________ General Chemistry Albumin Alkaline Phosphatase Alanine Aminotransferase Bilirubin: Total Direct Calcium Cholesterol, Total C-Reactive Protein Creatine Kinase Creatinine Electrolytes: Sodium Potassium Ferritin Fecal Immunochemical Testing Follicle Stimulating Hormone Gamma Glutamyl Transferase Glucose Fasting F Glucose Random Glucose Gestational Diabetes Screen Glucose Gestational Tolerance 2 h F Glucose Tolerance Non-Pregnant 2 h F Hemoglobin A1C HCG, Serum: Qualitative Quantitative Iron/TIBC/% Saturation Lipid Profile Luteinizing Hormone Magnesium Phosphate Prostate Specific Antigen Protein Electrophoresis Protein, Total Thyroid Stimulating Hormone, Progressive Triglycerides Urea Immunology/Serology Mononucleosis Test Nuclear Antibody Screen Rheumatoid Factor Cardiology Electrocardiogram Holter Monitor(pre-book with site) 00286(Rev2014-08) Therapeutic Drug Monitoring Carbamazepine Phenytoin Cyclosporine PRE-DOSE Sirolimus Cyclosporine 2 hr POST DOSE Tacrolimus Digoxin Valproate Lithium Complete Below For All Drugs Being Monitored: Drug To Be Monitored: ______________________ Dose Regimen ________ Drug Route ________ Last Dose Start ________ Complete __________ Next Dose Start ___________________________ Length of Time On This Dose Regimen _________ _________________________________________ If Antibiotics (Check one): Pre Post Interval Random Other Medications: _________________________ _________________________________________ Cytology (Non-Gynecological) Cytology Test Microbiology Bacterial Vaginosis Screen Clostridium difficile Toxin Ear Culture: Right Left Eye Culture: Right Left Fungal Screen: Hair Nail Skin Genital Culture: Cervix Vaginal Urethra Group B Strep: Vaginal Anorectal MRSA Screen: Groin Nasal Wound Nasal Culture Ova & Parasite Sputum Culture Stool Culture Throat, Group A Strep Urine Culture: MSU Catheter Cysto VRE Screen (Rectal) Wound: Superficial, less than 2 cm Deep, greater than 2 cm/surgical Specimen Source: History Specimen Site Antimicrobials (Specify) Specimen Type IgA IgG IgM Other Tests/Clinical Indications/Relevant History
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