Form# 103559 - Community Mobile Phlebotomy Requisition - Saskatoon Health Region printable pdf download

Form# 103559 - Community Mobile Phlebotomy Requisition - Saskatoon Health Region

Saskatoon Health Region

COMMUNITY MOBILE PHLEBOTOMY REQUISITION

To be used for Saskatoon and Area Residents Only

Clinical Diagnosis: _________________________________

PHN #: _____________________

Chart #: ___________

Requesting Physician: _____________________________

Name: ______________________________

 M

F

Last

First

Date of Birth: ______________________________

Phone #: ____________________

dd/mm/yy

Address: _____________________________________

Additional Copies of Report to: ____________________

Frequency:

 One time only

 Weekly

 Bi-weekly

 Every 4 weeks

IN ORDER TO QUALIFY FOR MOBILE SERVICE, YOUR PATIENT MUST MEET THIS CRITERION:

Client must be unable, either temporarily or permanently for reasons of a disability or poor health, to leave

their home.

Please check the appropriate box:

 Post-Op

 Disability

 2 – Man Transfer

 Bedridden

 Early Release from Hospital

 Other (must specify)

FAX COMPLETED REQUISITION TO 655-4021

PHYSICIAN SIGNATURE: _________________________________

(Required to process request)

CBC

 CBC (&diff)

 PT (INR)

APTT

 PTT (APTT)

ALP

 Alkaline Phosphatase

UREA

 Urea

CRCLE

 Est. Creatinine

Clearance

ALT

 Alanine Aminotransferase

CREAT

 Creatinine

Wt: _______ KG

AST

 Aspartate Aminotransferase

LYTE4

 Electrolytes (Na,K,Cl,CO2)

BILIT

 Bilirubin (total)

URIC

 Uric Acid

CARBZ

Carbamazepine

(Tegretol)

GGT

 Gamma Glutamyltransferase

 Calcium

PHENB

 Phenobarbital

LIP

 Lipase

PHOS

 Phosphate

DIGI

 Digoxin

 CK Total

 Magnesium

LITH

 Lithium

 Protein - Total

FER

 Ferritin



ALB

 Albumin

OTHER

 __________________

PTNY

 Phenytoin

CHOL

 Cholesterol

(Dilantin)

GLUCR

 Glucose - Random

VALPR

 Valproic Acid

(Epival)

HMA1C

 Hemoglobin A1C

Dosage: __________________

Date: _____________________

Time: _____________________

ALL INFORMATION MUST BE PROVIDED TO ENSURE PROCESSING IS NOT DELAYED

Word

Form# 103559

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Form# 103559 - Community Mobile Phlebotomy Requisition - Saskatoon Health Region

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