Pm Form # 101092 - Cervical Cytological (Pap) Requisition
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1Laboratory Medicine - Cytology
Client Information
Saskatoon City Hospital
701 Queen Street
Name: _________________________________________________________
Last
First
Middle
Saskatoon, SK S7K 0M7
PH: (306) 655-8480
HSN: _____________________ Date of Birth ____________
dd/mm/yyyy
FAX: (306) 655-8106
MRN: _______________________ Stay #: ____________________________
Address: ________________________________________________________
City
Province
Postal Code
CERVICAL CYTOLOGICAL (PAP) REQUISITION
________________________________________________________
In cooperation with:
Phone: (
) __________________
PREVENTION PROGRAM FOR CERVICAL CANCER
A Program of the Saskatchewan Cancer Agency
Guardian (if applicable) (name printed / signature)
1-800-667-0017
________________________________________________________________
Health Care Provider
Phys # ________________________
Copy of Report to Health Care Providers:
Name: ___________________________________________________
Name __________________________________
Last
First
Middle
Last
First
Middle
Clinic Address
Name __________________________________
City/Province/Postal Code
Last
First
Middle
Phone:
Fax:
PPCC: Prevention Program for Cervical Cancer
Email:
952 Albert Street, Regina, SK S4R 2P7
Specimen:
Collection Date:
______
_______
________
Collection Type:
Specimen Submitted
dd
mm
yyyy
Ecto/Endocervix
Vulva
Conventional PAP
One Slide
Two Slides
Vaginal:
Pool
Vault
Wall
Liquid Base PAP
Liquid Vial
Other Relevant Clinical History:
Clinical History:
LNMP: _____
_____
________
dd
mm
yyyy
Menstrual Cycle ______________________________
Pregnant (wks) _________ Gravida # ____________
Post Partum (wks) ________ Parida # __________
Menopause (yrs) _______
Post Menopausal Bleeding
Hysterectomy
Total
Subtotal ____ ____ ______
dd
mm
yyyy
IUD
Oral Contraceptive (OPC) _____________
Health Care Provider
HPV Confirmed Type: ______________________
Signature: ________________________________
HIV
Immunocompromised Type: __________________
LAB USE ONLY:
Treatment History:
Cryo
Date: ______ ______ _________
dd
mm
yyyy
Hormone Therapy Type: ___________________
Radiation
Date: ______
______
_________
dd
mm
yyyy
Chemo
Type/Date ______________________
Laser
Date: ______
______
_________
dd
mm
yyyy
Leep
Date: ______
______
_________
dd
mm
yyyy
Other
Date: ______
______
_________
Date Received
dd
mm
yyyy
Colposcopy Date: ______
______
_________
dd
mm
yyyy
Previous PAP Date: ______
______
________
dd
mm
yyyy
Lab Exam Number:
Lab Exam Number: ______________
PM Form # 101092
10/03
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