Fillable Outpatient-laboratory-requisition

Fill Online, Printable, Fillable, Blank Outpatient-laboratory-requisition Form

Use Fill to complete blank online ISLAND HEALTH pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Outpatient-laboratory-requisition

On average this form takes 23 minutes to complete

The Outpatient-laboratory-requisition form is 1 page long and contains:

  • 0 signatures
  • 83 check-boxes
  • 53 other fields

Country of origin: CANADA
File type: PDF

Use our library of forms to quickly fill and sign your Island Health forms online.

BROWSE ISLAND HEALTH FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
18 - 05 - 0358 - 0 REVISED Feb 2019
INSTRUCTIONS TO PATIENTS (see reverse)
ORDERING PRACTITIONER: ADDRESS, PHONE, MSP PRACTITIONER NUMBER
LOCUM FOR PRACTITIONER AND MSP PRACTITIONER NUMBER:
If this is a STAT order please provide contact telephone number:
Bill to →
MSP
ICBC
WorkSafeBC
PATIENT
OTHER:
PERSONAL HEALTH NUMBER
ICBC/WorkSafeBC NUMBER
LAST NAME OF PATIENT FIRST NAME OF PATIENT
DOB
YYYY MM DD
SEX
M
F
OTHER CONTACT NUMBER OF PATIENT
Pregnant?
YES
NO
Fasting? h pc
ADDRESS OF PATIENT
PROVINCE
CITY/TOWN
PRIMARY CONTACT NUMBER OF PATIENT
Copy to PRACTITIONER/MSP Practitioner Number:
Copy to PRACTITIONER/MSP Practitioner Number:
DIAGNOSIS
HEMATOLOGY URINE TESTS CHEMISTRY
Hematology prole On Anticoagulant?
Yes
No
INR Specify:
Ferritin (query iron deciency)
HFE - Hemochromatosis (check ONE box only)
Conrm diagnosis (ferritin rst, + TS, + DNA testing)
Sibling/parent is C282Y/C282Y homozygote (DNA testing)
MICROBIOLOGY –
LABEL ALL SPECIMENS WITH PATIENT’S FIRST & LAST NAME, DOB, PHN & SITE
Macroscopic → microscopic if dipstick positive
Macroscopic → urine culture if pyuria or nitrite present
Macroscopic (dipstick) Microscopic *
Special case (if ordered together)
ROUTINE CULTURE
On Antibiotics?
Yes
No Specify:
Throat Sputum Blood Urine
Supercial Wound , Site:
Deep Wound, Site:
Other:
VAGINITIS
Initial (smear for BV & yeast only)
Chronic/recurrent (smear, culture, trichomonas)
Trichomonas testing
GROUP B STREP SCREEN (Pregnancy only)
Vagino-anorectal swab Penicillin allergy
CHLAMYDIA (CT) & GONORRHEA (GC) by NAAT
Source/site:
Urethra Cervix Urine
Vagina Throat Rectum
Other
GONORRHEA (GC) CULTURE
Source/site:
Cervix Urethra Throat Rectum
Other
STOOL SPECIMENS
History of bloody stools?
Yes
C.dicile testing Stool culture Stool ova & parasite exam
Stool ova & parasite (high risk, submit 2 samples)
DERMATOPHYTES
Dermatophyte culture KOH prep (direct exam)
Specimen:
Skin Nail Hair
Site:
MYCOLOGY
Yeast Fungus Site:
HEPATITIS SEROLOGY
Acute viral hepatitis undened etiology
Hepatitis A (anti-HAV lgM)
Hepatitis B (HBsAg + anti-HBc)
Hepatitis C (anti-HCV)
Chronic viral hepatitis undened etiology
Hepatitis B (HBsAg; anti-HBc; anti-HBs)
Hepatitis C (anti-HCV)
Investigation of hepatitis immune status
Hepatitis A (anti-HAV, total)
Hepatitis B (anti-HBs)
Hepatitis marker(s)
HBsAg
(For other hepatitis markers, please order specic test(s) below)
HIV Serology
(patient has the legal right to choose not to have their name and
address reported to public health = non-nominal reporting)
Non-nominal reporting
LIPIDS
one box only
Note: Fasting is not required for any of the panels but clinician may
specically instruct patient to fast for 10 hours in select circumstances
[e.g. history of triglycerides > 4.5 mmol/L], independent of laboratory
requirements.
Full Lipid Prole - Total, HDL, non-HDL, LDL cholesterol,
& triglycerides (Baseline or Follow-up of complex dyslipidemia)
Follow-up Lipid Prole - Total, HDL & non-HDL cholesterol only
Apo B (not available with lipid proles unless diagnosis of
complex dyslipidemia is indicated)
OTHER TESTS –
FIT (Age 50-74 asymptomatic q2y) Copy to Colon Screening Program
FIT No copy to Colon Screening Program
SIGNATURE OF PRACTITIONER
DATE SIGNED
TELEPHONE REQUISITION RECEIVED BY: (employee/date/time)
Standing Orders Include expiry & frequency
The personal information collected on this form is collected under the authority of the Personal Information Protection Act. The personal information is used to provide medical services requested on this
requisition. The information collected is used for quality assurance management and disclosed to healthcare practitioners involved in providing care or when required by law. Personal information is protected
from unauthorized use and disclosure in accordance with the Personal Information Protection Act and when applicable the Freedom of Information and Protection of Privacy Act and may be used and disclosed
only as provided by those Acts.
DATE OF COLLECTION
TIME OF COLLECTION
CURRENT MEDICATIONS/DATE AND TIME OF LAST DOSE
COLLECTOR
INSTRUCTIONS TO PATIENTS (See reverse)
Other Instructions:
Creatinine / eGFR
Calcium
Creatine kinase (CK)
PSA – Known or suspected prostate
cancer (MSP billable)
PSA screening (self-pay)
Pregnancy test
ß-HCG – quantitative
HLTH 1901 2018/05/30
Glucose – fasting (see reverse for patient instructions)
Glucose – random
GTT – gestational diabetes screen (50 g load, 1 hour post-load)
GTT – gestational diabetes conrmation (75 g load, fasting, 1 hour
& 2 hour test)
GTT – non-gestational diabetes
Hemoglobin A1c
Albumin/creatinine ratio (ACR) - Urine
ECG
THYROID FUNCTION
For other thyroid investigations, please order specic tests below and
provide diagnosis.
Monitor thyroid replacement therapy (TSH Only)
Suspected Hypothyroidism (TSH rst, fT4 if indicated)
Suspected Hyperthyroidism (TSH rst, fT4 & fT3 if indicated)
OTHER CHEMISTRY TESTS
Sodium
Potassium
Albumin
Alk phos
ALT
B12
Bilirubin
GGT
T. Protein
For tests indicated with a blue tick box
, consult provincial guidelines and protocols (www.BCGuidelines.ca)
https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines
SECONDARY CONTACT NUMBER OF PATIENT
POSTAL CODE
✓
PRINT
RESET
LABORATORY REQUISITION
Department of Laboratory Medicine, Pathology & Medical Genetics
This requisition form when completed constitutes a referral to Island Health laboratory physicians
Blue Highlighted elds
must be completed.
SAVE FORM
PRINT FORM
ATTACH TO EMAIL
RESET FORM
ALL SITES ARE WHEEL CHAIR ACCESSIBLE
Hours of operation are subject to change.
For the most current information, visit our website at
http://www.viha.ca/laboratory_medicine/
YOU WILL BE ASKED TO PRESENT YOUR
CARE CARD AT EACH VISIT
Community Laboratory Services
Location Hours of Operation Fax/Phone
South Island Laboratories
Admiral's Walk Mon-Fri 7:30 am - 12:00 pm Fax 250-480-7875
108-1505 Admirals Road, Victoria (noon)
Brentwood Satellite Laboratory Mon-Fri 7:30 am - 12:00 pm Fax 250-652-7054
1-7120 West Saanich Road, Brentwood Bay (noon)
Galiano Island Health Unit Thurs 7:00 am - 10:30 am Phone 250-539-3230
908 Burrill Street, Galiano Island Fax 250-539-3238
Keating Cross Road Laboratory Mon-Fri 7:30 am - 12:00 pm Fax 250-544-8253
2140A Keating Cross Road, Victoria (noon)
Lady Minto Hospital Mon-Fri 7:30 am - 1:45 pm Phone 250-538-4812
135 Crofton Road, Saltspring Island Fax 250-538-4817
Mayne Island Health Clinic Wednesdays 7:30 am - 10:30 am Phone 250-539-2312
100-466 Felix-Jack Road, Mayne Island Fax 250-539-3215
Pender Island Health Unit Call for appointment Phone 250-629-3233
5715 Canal Road, North Pender
Royal Jubilee Hospital Mon-Fri 7:00 am - 5:00 pm Fax 250-370-8482
1952 Bay Street, Victoria Sat 7:30 am - 12:00 pm
Sun 9:00 am - 1:00 pm
Saanich Peninsula Hospital Mon-Fri 8:00 am - 5:00 pm Fax 250-652-7589
2166 Mt. Newton Cross Road, Saanichton Sat 9:00 am - 1:00 pm
Saanich Road Laboratory Mon - Fri 8:00 am - 4:00 pm Fax 250-381-8079
201-3491 Saanich Road, Victoria Closed 12:00 pm (noon) - 12:30 pm
Sidney Satellite Laboratory Mon - Fri 7:00 am - 6:00 pm Fax 250-655-0783
2357 James White Blvd, Sidney Sat - 7:00 am - 2:30 pm
Victoria General Hospital Mon - Fri 7:00 am - 5:00 pm Fax 250-727-4371
1 Hospital Way, Victoria
Centre Island Laboratories
Chemainus Health Care Centre Mon-Fri 7:30 am - 3:30 pm Phone 250-737-2040 ext 42238
9909 Esplanade Street, Chemainus Fax 250-737-2058
Cowichan District Hospital Mon - Fri 7:00 am - 5:00 pm Phone 250-737-2030 ext 44268
3045 Gibbins Road, Duncan Sat - 8:00 am - 12:00 pm Fax 250-709-3004
Ladysmith Community Health Centre Mon - Fri 7:30 am - 3:30 pm Phone 250-739-5786
1111 - 4th Ave, Ladysmith Sat - 8:00 am - 11:00 am Fax 250-740-2699
Nanaimo Regional Hospital Mon - Fri 8:00 am - 4:00 pm Phone 250-755-7607
1200 Dufferin Cres, Nanaimo Sat - Sun call for appointment Fax 250-755-7625
Nanaimo Regional Hospital Sat Lab details: Mon - Fri 7:15 am - 5:00 pm Phone 250-755-7623
#2 - 1599 Dufferin Cres, Nanaimo Sat - 7:15 am - 1:30 pm closed at lunch 10:30 - 11:00 am Fax 250-755-6216
Tono General Hospital Mon & Fri 12:30 pm - 2:30 pm Phone 250-725-4006
261 Neil Street, Tono Tues, Wed, Thurs 8:30 - 11:30 am Fax 250-725-4015
Ucluelet Tues & Thurs 7:30 am - 11:30 am Phone 250-726-2296
1566 Peninsula Ave, Ucluelet Fax 250-726-7333
West Coast General Hospital Mon - Fri 7:00 am - 3:30 pm Phone 250-724-8808
3949 Port Alberni Hwy, Port Alberni Sat - Sun call for appointment Fax 250-724-8831
North Island Laboratories
Campbell River General Hospital Mon - Fri 6:30 am - 5:00 pm Phone 250-286-7100 ext 67447
375 Second Ave., Campbell River Sat - 6:30 am - 2:00 pm Fax 250-286-7127
Cormorant Island Health Centre Mon - Fri 9:30 am -11:30 am Phone 250-974-5585 ext 66343
49 School Road, Alert Bay Mon -Thurs 1 pm - 2 pm Fax 250-974-5422
Courtenay Laboratory Mon - Fri 8:00 am - 3:30 pm Phone 250-331-8508
307-14th St., Courtenay Fax 250-331-8514
Comox Valley Hospital Laboratory Mon - Fri 6:30 am - 5:00 pm Phone 250-331-5950
101 Lerwick Ave., Courtenay Fax 250-331-5933
Cumberland Health Centre Mon - Fri 7:30 am -11:00 am Phone 250-331-8577
2696 Windermere Ave, Cumberland Fax 250-331-8578
Port Alice Health Centre Call for Appointment Phone 250-284-3555
1090 Marine Dr, Port Alice Fax 250-284-6163
Port Hardy Hospital Mon - Fri 8:30 am - 2:00 pm Phone 250-902-6015
9120 Granville St, Port Hardy Fax 250-902-6031
Sat - Sun 8:30 am - 9:30 am
and 1:00 pm - 2:00 pm
Port McNeill Hospital Mon - Sun 8:30 am-9:30 am Phone 250-956-4461 ext 66228
2750 Kingcome Place, Port McNeill and 1:00 pm - 2:00 pm Fax 250-956-4423
Quadra Medical Clinic Laboratory Wed & Fri 7:00 am - 10:00 am Phone 250-850-2654
Quathiaski Cove, Quadra Island
St. Joseph's Laboratory Mon - Fri 7:00 am - 3:00 pm Phone 250-331-8634
2137 Comox Ave, Comox Fax 250-331-8635
FOR TEST RESULTS AND GENERAL INFORMATION
Call the Laboratory Call Center
Phone (250) 370-8355 Toll Free 1-866-370-8355
Hours : Monday to Friday: 7:00 am to 6:00 pm
Saturday and Stat Holidays: 8:00 am to 4:00 pm
Closed Sundays
TESTS REQUIRING APPOINTMENTS
ECG’s are available at most sites.
No appointment necessary -
EXCEPT Lady Minto Hospital - phone 250-538-4800
Holter Monitoring and Treadmill Tests
●
Appointment required.
●
Only available at certain locations.
Physicians Must Book
●
Bone Marrows
●
Stimulation/Suprression Tests
●
Autologous Blood Donation - Call 250-370-8454
FOR SAMPLES DROPPED OFF
●
Sample label must include full legal name, date of
birth, insurer number, and date and time of collection
●
Requisition must have the above plus name, MSP #
and signature of ordering doctor
PATIENT INSTRUCTIONS
Urine for culture, macroscopic, microscopic tests
●
If sample cannot be delivered to lab within 2h of
collection, refrigerate immediately and deliver
as soon as possible.
Fasting Instructions
●
Do not eat or drink (except water as required for
thirst) for at least 8h (6h if pregnant) before the test.
●
Do not exceed 12h fast (8 h if pregnant).
Glucose Tolerance Tests (GTT)
●
Follow fasting instructions.
●
Maintain usual diet for at least three days prior to test
Therapeutic (Medication) Blood Level
●
For most medications the blood sample is optimally
collected just prior to the next dose of medication.
●
Digoxin - Blood sample is usually collected 8h
after the last dose of medication.
●
Lithium - Blood sample is usually collected 12h
after the last dose of medication.
Cortisol
●
For morning (AM) cortisol levels, please arrive within
3h of awakening and prior to 10:00 am.
●
May be required to rest for 30 minutes after arrival at lab.
●
For a morning (AM) and afternoon (PM) cortisol,
tests should be performed on the same day.
Call for appointment
Sat - 9:00 am - 1:00 pm
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Outpatient-laboratory-requisition

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 3 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document