Central Zone Laboratory Requisition Patient

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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