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