Requisition For Specimen Containers And Supplies - Public Health Ontario
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Customer No.:
Requisition for Specimen Containers and Supplies
Please note: That specimen containers and supplies are supplied to submitters exclusively for samples that are
to be tested by the Public Health Ontario Laboratories.
Requisitioner’s name
Ship to (include Client name, Address and Postal code):
Telephone no.
Fax no.
(
)
(
)
Date
Authorized signature
Name
Item#
Kits
UoM
Quantity
Name
Item#
Kits
UoM
Quantity
Chlamydia
Prenatal
390050
Rubella, Syphilis, Hep.B, HIV
PKG/6
300210
Unisex swab kit
Box of 50
trachomatis &
Neisseria
Swab in transport medium
Virus Culture
300209
Urine collection kit
Box of 50
390081
PKG/6
gonorrhoeae
(Universal Transport Media-UTM)
- Herpes/STI
DF
390047
Direct Fluorescence
EA.
Virus -
Nasopharyngeal swab in
PKG/6
Respiratory
390082
Enteric
transport medium
(Universal
3 vials (Enteric Bacteriology,
/ Influenza
390036
EA.
Virus Culture and Parasitology)
Outbreak kit
Transport Media-UTM)
FAECES
390049
Enteric Bacteriology (Cary Blair)
EA.
Virus -
Virus culture/electron microscopy/
390087
PKG/6
Enteric
PCR & direct antigen testing
GL
EA.
390043
Gastric Lavage - M. tuberculosis
Description
Item#
UoM
Quantity
PARA
390033
Faeces - Routine Parasitology
PKG/3
Biohazard Bags - Clinical Specimens (Self-Seal)
300008
PKG/100
TB kit Sputum Body fluids and
TB
390042
EA.
tissues (90 ml sterile container)
Test Requisition Bacterial Analysis of Food
300164
PKG/100
(Form # 1722-44)
C.difficile analysis or toxin studies
CD
EA.
390054
(90 ml sterile container)
Test Requisition Bacterial Analysis of Water
(Private Citizen - single sample)
Virus-H
390041
HIV / AIDS
EA.
PKG/100
300087
(Form # 3743-44)
Virus Culture
EA.
390075
Universal Transport Media (UTM)
(tissue)
Test Requisition Bacterial Analysis of Water
(Official Agency - multiple sample)
300089
PKG/100
EA.
Private Citizen Water - bacteriological
390040
(Form # 4321-44)
Water
Sterile - Water bottles - 250 ml
Test Requisition Bacterial Analysis of Water
300013
EA.
(Official Agency Use Only)
(Official Agency - single sample)
300088
PKG/250
(Form # 4318-44)
PWO kit
390045
Pinworm Ova Kit
EA.
Test Requisition Environmental Swabs
Blood, clotted
300115
PKG/250
390044
(Form # 185-44)
BL-S
PKG/6
Serology - Syphilis / Virus / Other
BP
390052
Bordetella pertussis (Whooping cough)
PKG/2
Test Requisition
(Form # 1210-44B) HIV
300085
PKG/100
Chlamydia trachomatis
PKG/6
390083
Female
General Test Requisition (Form # 97-44) PHL
300122
PKG/100
culture
(
CHL(C)
Universal
390084
PKG/6
Male
Transport Media-UTM )
Test Requisition Prenatal
(Form # 1739-44)
PKG/250
300086
Mycoplasma pneumoniae /
MP/CP -
390085
PKG/6
Chlamydophila pneumoniae - Respiratory
Resp
Test Requisition Reference Bacteriology
300091
PKG/250
(Form # 98-44)
F
390048
Fungus Dermatophytes
PKG/6
Vacutainer Tubes (SST) (Tiger Top)
300200
PKG/100
GC
390051
Neisseria gonorrhoeae culture
PKG/6
Genital Mycoplasma/Ureaplasma culture
MP
390064
PKG/6
( Universal Transport Media-UTM )
Comments: _____________________________________________
Date order received
(yyyy/mm/dd)
Order filled by
Date order shipped (yyyy/mm/dd)
Current version of Public Health Laboratory requisitions are available at
F-SD-SCG-1003-006
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