Form # 103029 - Request For Perinatal Testing - Canadian Blood Services printable pdf download

CANADIAN BLOOD SERVICES

SASKATCHEWAN CENTRE

2571 Broad Street

Regina, Sk. S4P 3B4

REQUEST FOR PERINATAL TESTING

FAX REPORT TO:

Note: This area must be completed in full or the

samples will not be tested.

Doctor ________________________________________

Last Name _____________________________________

(Initial)

(Last Name)

Clinic _________________________________________

First Name _____________________________________

Address _______________________________________

PHN ___________________ DOB___________________

YYYY/MM/DD

________________________________________

Phlebotomist:

Signature ______________________________________

City ________________ Postal Code ________________

Collection Date _________________________________

Fax

________________ Phone _____________________

Copy to additional Physician: (if applicable)

Sample Type:  First Visit

 Father*

Doctor __________________________________________

 26 – 28 Weeks

 Cord*

(Initial) (Last Name)

 Other ___________________

Address _________________________________________

Expected Delivery Date ____________________________

YYYY MM DD

_________________________________________

Hospital for Delivery _______________________________

City ________________ Postal Code __________________

# of Previous Pregnancies __________________________

Fax

________________ Phone ______________________

 No  Yes Describe ______________

Antibodies:

*NOTE: If sample is Father/Cord

this section Must be Completed:

 No  Yes Describe ______________

Transfusion:

Mother’s Name __________________________________

 No  Yes Date __________

Rhlg Administered

Last

First

Mother’s PHN ____________________________________

Collection

Step

Action

Procedure

INFORMATION ON SAMPLES AND REQUISITION MUST BE IDENTICAL, COMPLETE

AND LEGIBLE

Collection requirements – 2 X 5 ml EDTA (lavender top)

Samples and Requisitions must be labeled with the patient’s first and last name and at

least one of the following:



Personal Health Identification Number (PHN)



Other Unique Identification Number

Note: If recently married submit both names

The phlebotomist must complete the requisition by:



Signing his/her name



Recording the date of collection



Acknowledging and correcting any errors or omissions on the requisition

For Results Fax – (306)‐347‐1552

Accession #

Word

Form # 103029

05/14

Category: Requisitions

Form # 103029 - Request For Perinatal Testing - Canadian Blood Services

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