Form Ch-0312 - Hematology Specialty Requisition Form
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1Hematology Specialty
Accession #
LABORATORY MEDICINE AND PATHOLOGY
Requisition
Client Response Centre
780-407-7484
CAPITAL HEALTH REGION LABORATORIES
PHN / Healthcare Number
DynaLIFE
DIAGNOSTIC LABORATORY SERVICES
DX
D
Patient Legal Name (Last)
(First)
(Initial)
DD
MM
YY
M
Full Name & Location MUST BE PROVIDED
O
F
B
Copy to
Name ___________________________________
Address
City
Prov.
Postal Code
Physician Code ___________________________
Address _________________________________
Chart #
Patient Phone #
Lab #
________________________________________
Ordering Physician / Practitioner
Physician Code
Specimen Event Type
Bill Type CPL
Alberta Health Care
IA
AUXILIARY
CCO
Capital Health Company
IP
IN PT
CO
Company
XX
Pre-paid
OP
OUT PT
Ordering Address / Location
Report Location Code
OT
Out of Prov
PB
Patient Bill
AP
AMBUL
HC
HMCARE
Co. name ____________________________________________
ST
STAFF
Report address if different
Address _____________________________________________
EN
ENVIRON
WCB
WORKER’S
Client # ______________________________________________
COMP
Date specimen collected
Col. Location
DD
MM
YY
TIME (24 h)
Collector
Fasting
# of hours
SPECIAL HEMATOLOGY / COAGULATION
BLOOD SMEAR & / OR BONE MARROW ASPIRATE
CELL MARKER STUDIES
FACS
Sent to UAH
Bone Marrow
PTTIN
PTT inhibitor
Examination Required
F8
Factor VIII
PC
Peripheral blood film
XFACS
Send to CCI
Blood
Other coagulation factors
CYTOGENETICS
Bone marrow aspiration / biopsy
(specify) ___________________________
Cancer Specimens - Specimen Type
(Pre-book at 407-3000 for UAH patients)
VWFAG
Von Willebrand factor antigen
BM(AP)
Karyotype, bone marrow aspirate
Routine Culture (C&S)
RISTO
Ristocetin cofactor
B(AP)
Karyotype, unstimulated blood
T.B.
Viral
Fungal
BT
Bleeding time (phone - 780-407-3000)
OTHER
Karyotype ________________________
(Microbiology Requisition must be completed)
F8INH
Factor VIII inhibitor titre
Indications for test ____________________________
MAL
Malaria film
AT3
Antithrombin
____________________________________________
Travel history ______________________
PROTC
Protein C
____________________________________________
History and object of examination
PROTS
Protein S
MOLECULAR PATHOLOGY
APCE
APC resistance (clot-based)
Specimen type:
APCGN
APC resistance (Factor V Leiden)
Blood
PROM
Prothrombin G20210A
Bone Marrow
LUP
Lupus anticoagulant
Other, (specify) ____________________________
APA
Antiphospholipid antibodies
HCYSE
Homocysteine (fasting _____________ h)
IgH gene rearrangement
TT
Thrombin time
t(14;18) IGH@IBCL2
REPT
Reptilase time
t(11;14) IGH@ICCND1
PLGN
Plasminogen
T cell receptor gamma TRG@
Recent transfusions
T cell receptor beta TRB@
Heparin levels (anti-Xa)
Quantitative t(9;22) BCR / ABL1
UNFH
Unfractionated heparin
PGM3 Immunofluorescent assay for t(15;17) –
LMWHB
Low mol. wt. heparin
(for initial diagnosis only)
Must specify type: ____________________________
t(15;17) PML / RARA
Time / date of last dose: _______________________
t(8;21) RUNX1 / RUNX1 T1
Pertinent drug history
ORGRN
Orgaran
JAK2 V6I7F mutational analysis
Other (specify) ____________________________
HIT
Heparin-induced thrombocytopenia
Must specify type / brand of heparin _____________
OTHER TESTS
____________________________________________
Physical findings
Time / date of last heparin dose ________________
No
Yes Degree
____________________________________________
Splenomegaly
___________________
TLYM
T-lymph subsets
(CD3 / 4 / 8)
Hepatomegaly
___________________
G6PDS
G6PD
Lymphadenopathy
___________________
PKS
Pyruvate kinase
Other _______________________________________
OF
Osmotic fragility
FOR LAB USE ONLY
LAP
Leukocyte alkaline phosphatase score
Site
Iliac crest
Rt
Lt
Post
Ant
FETAL
Fetal cell stain (Kleihauer Betke)
Sternum
Tibia
HBFS
Hb F/S quantitation
Operator: Dr. ________________________________
CH-0312 Sep 2008
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