Form Ch-0311 - Chemistry Specialty Requisition Form
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1Accession #
Chemistry Specialty
LABORATORY MEDICINE AND PATHOLOGY
Client Response Centre
780-407-7484
Requisition
CAPITAL HEALTH REGION LABORATORIES
PHN / Healthcare Number
DynaLIFE
DIAGNOSTIC LABORATORY SERVICES
DX
V Copy to
D
V M
Patient Legal Name (Last)
(First)
(Initial)
DD
MM
YY
O
Name ___________________________________
V F
B
Physician Code ___________________________
Address
City
Prov.
Postal Code
Address _________________________________
Chart #
Patient Phone #
Lab #
________________________________________
Bill Type CPL V Alberta Health Care
Ordering Physician / Practitioner
Physician Code
Specimen Event Type
V Capital Health Company
CCO
V AUXILLARY
IA
CO V Company
V Pre-paid
V IN PT
XX
IP
V OUT PT
OP
Ordering Address / Location
Report Location Code
OT V Out of Prov
V Patient Bill
PB
V AMBUL
AP
V HMCARE
HC
Co. name ____________________________________________
V STAFF
ST
Report address if different
Address _____________________________________________
V ENVIRON
EN
V WORKER’S
WCB
Client # ______________________________________________
COMP
V PRIORITY
Date specimen collected
Col. Location
DIAGNOSIS:
DD
MM
YY
(specify tests)
TIME (24 h)
Collector
Phone to
Fasting
______________
# of hours
TRACE ELEMENTS
ALLERGENS
SPECIMEN TYPE
Strict attention to recommended specimen collection
Strict attention to recommended specimen collection
Blood V serum
V plasma
V whole blood
procedures is required. Information can be obtained from
procedures is required. Information can be obtained from
V total IgE quantitation
V amniotic
V pleural
V CSF
IGE
Fluid
“Guide to Lab Services” or by calling client response centre
“Guide to Lab Services” or by calling client response centre
V synovial
V peritoneal
V other ________
FOODS V food screen
780-407-7484.
780-407-7484
V dialysate ___________
V perit. dialysate
V inhalant screen
INHS
THE FOLLOWING MUST BE COMPLETED FOR
V Random
V 24h
V 72h
Urine / Feces
INSEC V stinging insect panel
TRACE ELEMENT ANALYSIS
V Timed, other ________ Total volume __________
Environmental exposure to certain trace elements either
PENGV V penicillin G and
occupationally or in food / medications can cause elevated
Start time _____________ Stop time _____________
amoxicillin
trace element concentrations. It is important to note all
Other _______________________________________
relevant patient information.
MISCELLANEOUS
V Smoker
V Non-smoker
FOODS
V Fecal fat (72 h collection) Refer to
FFAT
V Recent ingestion of seafood ______________________
V codfish
COD
collection Protocol in Guide to Services
V Occupational exposure __________________________
V egg white
V Fetal lung maturity
EGG
FLM
Time of exposure ________________________________
(amniotic fluid: forward to RAH)
V milk
MILK
V 25 - OH Vit D
VITD
Trace elements suspected _________________________
V peanut
PNUT
AUTOIMMUNE
_______________________________________________
V soybean
SOYA
V thyroid microsomal Ab
TPO
Drugs prescribed or taking _________________________
WHEAT V wheat
ACHRQ V acetylcholine receptor Ab
_______________________________________________
V transglutaminase Ab
ATTG
Other pertinent information / tests ____________________
MICROORGANISMS
BIOCHEMICAL GENETICS
_______________________________________________
V alternaria tenuis
Blood
ATEN
V amino acid quantitation
AAQ
SINGLE TRACE ELEMENTS
ASPFM V aspergillus fumigatus
V amino acid screen
AA
Urine
Serum
Blood
CHERB V cladosporium herbarum
V carnitine
CARN
V UAL
V AL
Aluminum
V penicillium notatum
PNOT
Urine
V UAS
V BAS
Arsenic
V amino acid screen
UAA
V BCDM
Cadmium
ORGLC V organic acids
EPIDERMALS
V UCRM
V CRM
Chromium
MPSCR V mucopolysaccharide screen
V cat dander
CAT
V UCOB
Cobalt
V oligosaccharide screen
OLIGO
V cow dander
COW
V UCU
V CU
V sugar identification
Copper
SUGID
V dog epithelium
DOG
V UPB
V BPB
Lead
OTHER TESTS
HORSE V horse dander
V BMN
Manganese
V UHG
V BHG
Mercury
V UNIK
V NIK
TREE, GRASS, WEED POLLENS
Nickel
V USEL
V SEL
BIRCH V birch
Selenium
V UZN
V ZN
V timothy grass
Zinc
TIMO
TRACE ELEMENT SCREEN
RWEED V western ragweed
UTREL V urine
aluminum, antimony, arsenic, barium,
beryllium, bismuth,cadmium, copper,
MITES
lead, manganese, mercury, selenium,
DPTER V D. pteronyssinus mite
thallium, zinc
V serum aluminum, antimony, barium,
V D farinae mite
TREL
DFAR
beryllium, copper, nickel, selenium,
zinc
OCCUPATIONAL
BTREL V blood
cadmium, cobalt, lead, manganese,
LATEX V Latex
molybdenum, thallium
CH-0311 Sep 2008
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