Non-Gynecological Cytopathology Requisition Form
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1®
NON-GYNECOLOGICAL
CYTOPATHOLOGY REQUISITION
* REQUIRED INFORMATION
* PHYSICIAN TO ACT ON RESULTS:
PROVINCE
PERSONAL HEALTH NUMBER (PHN)
REGIONAL HEALTH
RECORD NUMBER
___ __ ___ ___ ___ --- ___ ___ ___ ___
Physician Last Name /
Full First Name:
PATIENT LAST NAME
FULL FIRST NAME
MIDDLE NAME
5 Digit Client #:
P
A
T
E I
N
T
A
D
D
R
E
S
S
C
T I
, Y
P
R
O
V
N I
C
E
P
O
S
T
A
L
C
O
D
E
Alpha Suffix Provider #:
CHART NUMBER
GENDER
DATE OF BIRTH
PATIENT PHONE NUMBER
__ __ __ __ / __ __ / __ __
( __ __ __ ) __ __ __ - __ __ __ __
Y Y Y Y
M
M
D D
* PROCEDURE PERFORMED BY:
SAME NAME / LOCATION AS ABOVE
* CURRENT SPECIMEN TAKEN:
FOR LAB USE ONLY - ACCESSION NUMBER
__ __ __ / __ __ / __ __
Date: __
______________________ _______________________ _____________________
Y Y Y Y
M M
D D
Last Name
Full First Name
Location
__ __ : __ __
Time:
H H
M M
ADDITIONAL COPIES TO:
Office
Other ____________
1) ______________________ _______________________ ____________________
FMC-WHC
TBCC/Holy Cross
Last Name
Full First Name
Location
ACH
FMC
PLC
RGH
In-patient
Out-patient
2) ______________________ _______________________ ____________________
Day Care
Unit # ______
Last Name
Full First Name
Location
SPECIMEN COLLECTION METHOD
BAL
Brush
Fluid
FNA
Scrape
Wash
Other: _________________
NON-GYNECOLOGICAL SPECIMEN SITE (You must complete a separate requisition for each specimen)
Ascites
Neck: ____________________________________
Bone: ____________________________________
Pancreas: ________________________________
Breast: ___________________________________
Pelvis: ___________________________________
Bronchus: _________________________________
Pericardium
Common Bile Duct: _________________________
Pleura: ___________________________________
CSF:
lumbar puncture
shunt
Retroperitoneum: __________________________
Esophagus: _______________________________
Salivary Gland : ____________________________
Gastric: __________________________________
Soft Tissue: _______________________________
Kidney: __________________________________
Sputum
Liver: ____________________________________
Thyroid: __________________________________
Lung: ____________________________________
Urine:
voided
catheterized
Lymph node: ______________________________
Other: ___________________________________
CLINCAL INFORMATION (Please print clearly)
FOR LAB USE ONLY – Prep notes
FOR LAB USE ONLY – Screener
FOR LAB USE ONLY – Pathologist
Laboratory Information Centre: 403-770-3600 • 1-800-661-3450
CLS Form# REQ9041CY-NON
rev. 20110415
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