Patient Sample Information Waiver Fax Form

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Saskatchewan
5 Research Drive
Ministry of
Saskatchewan Disease Control Laboratory
Regina, SK S4S 0A4
Health
(306) 787-3131
Patient Sample Information Waiver FAX Form
As defined by Saskatchewan Disease Control Laboratory (SDCL) Test Request and Laboratory Sample
Acceptance Criteria, this sample will NOT be processed unless this waiver is returned. Provide the
information required below and sign the completed form. Attach a cover sheet and return to SDCL by
FAX: (306)787-7252 as soon as possible (samples held for 7 days).
Waiver sent by__________________.
To: Health Care Provider at FAX Number: ______________________________ Date: ______________
_______________________________________________________________________________________
Patient Name: _______________________________________________________________
HSN: _________________
Samples submitted for Zika Virus testing must meet certain criteria set by the reference
laboratories performing the testing. Samples that do not have all of the required information will be
rejected. Please provide the following missing information:
TRAVEL LOCATION __________________________
TRAVEL DATES ______________________________
SYMPTOMS ______________________________
ONSET DATE ________________________________
COLLECTION DATE _______________________
On behalf of the Patient’s Health Care Provider, I verify that I have corrected &/or added the
information as requested above:
NAME (Please print): _____________________________________________________________
SIGNATURE: _________________________________________ Date: __________________
Note: Attach a cover page to this waiver and fax to SDCL at FAX (306)787-7252.
CONFIDENTIALITY NOTICE: This FAX was intended for a specific recipient. It may contain information that is privileged, confidential or
exempt from disclosure. Any privilege that exists is not waived. If you are not the intended recipient: do not copy it, distribute it to another
person or use it for any other purpose; shred it and advise sender by return fax or telephone.
Zika Waiver Form
Page 1 of 1
Effective Date: May 29, 2013

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