Pm Form # 101214 - Allergy Testing Requisition Form - Saskatoon Health Region printable pdf download

Pm Form # 101214 - Allergy Testing Requisition Form - Saskatoon Health Region

SASKATOON HEALTH REGION

Clinic name or billing info: ________________________

_________________________________________________

ALLERGY TESTING REQUISITION

_________________________________________________

PHN# _____________________ Chart# ____________

Clinical Diagnosis ______________________________

Name ________________________________________

Last

First

Requesting Physician ___________________________

q M

q F

Additional Copies of Report to: ___________________

Date of birth _______________ Phone ______________

Collection Date: _______________ Time: __________

DD/MM/YY

IGE

Total IGE

INHAL

Inhalant Screen

(a mixture including pollens, moulds, danders)

Food Screen

FX5

(a mixture of eggwhite, milk, cod, peanut, wheat, soy)

Allergens and other Allergy Tests: list below

ALLER

This requisition must accompany the serum sample and be sent to Room 4900,

Royal University Hospital.

Please ensure that all information is complete.

A positive screen will be followed up as appropriate.

Consult with Department of Lab Medicine - Chemistry (655-2164) for specific testing

available.

PM Form # 101214 (S)

10/04

Pm Form # 101214 - Allergy Testing Requisition Form - Saskatoon Health Region