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Molecular Genetics Laboratory

BC Children’s Hospital & BC Women’s Hospital

Request for Shipment

2J40 - 4500 Oak Street, Vancouver, BC V6H 3N1

(604) 875-2852 

(604) 875-2707

Phone

Fax

 moleculargenetics@cw.bc.ca 

Out-of-Province Genetic Testing

L1050



Facility Code

From:

Molecular Genetics Laboratory (MGL)

To:

Fax:

604-875-2707

Fax:

Date:

604-875-2852

Phone:

# Pages:

COMPLETE FOR EACH SAMPLE & EACH REFERRAL LABORATORY

RIORITY

AMPLE

YPE

STAT



LOOD

EDICAL

ENETICS

NLY

(affects pregnancy management)

___________

EDD:

___

__________

;

 T

CVS

MNIOCENTESIS

ISSUE

Path #:

DD/MMM/YY

DNA

Cultured

Uncultured*



_____________

;

 DNA*

MGL Sample ID:

*consultation required

ROUTINE



*prior approval required, as per policy

(quantity, # flasks, etc.)

PECIAL

NSTRUCTIONS

____

Quantity:

ug/ul &

_____________________________________________

EQUESTOR

NFORMATION

ATIENT

NFORMATION

Ordering Physician Last Name

Ordering Physician First Name

Last Name

First Name

Contact Person (if differs from Ordering Physician)

Personal Health Number

Date of Birth (DD/MMM/YY)

Contact Phone Number (if differs from above)

Gender

Referring Clinic ID

 M

 F

 UNK

& T

EFERRAL

ABORATORY

EST

NFORMATION

Referral Laboratory

Disorder or Test Requested

Shipping Address:

MGL U

NLY

HECKLIST

SHIPMENT

MSP funding approval letter



LABEL

Referral lab paperwork (requisition, consent form, etc)



Consent to Release Information Form (Bill 73 consent)**





** Only required for shipment outside of Canada

CM_PW

Document # CWMG_REQ_0210F Version # 3.2 Revised: October 2014

PRINT FORM

CLEAR ALL FIELDS

CLEAR PATIENT FIELDS

CLEAR PATIENT & LAB FIELDS

CONFIDENTIALITY NOTICE

The documents accompanying this fax transmission contain confidential information belonging to the sender which is legally privileged. The information is intended for the use of only the individual or entity

named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or taking of any action in reliance on or regarding the contents of this faxed information is

strictly prohibited. If you have received this fax in error, we apologize and ask that you immediately notify the sender by telephone to arrange for return or destruction of the document.