MM 1000107776 (2020-05-04)
TEM 005 Rev 01
Canadian Blood Services
use only
CANADIAN BLOOD SERVICES - DIAGNOSTIC SERVICES
PERINATAL SCREEN REQUEST
NOTE: Blood samples ARE NOT collected at Canadian Blood Services.
Go to Lifelabs or another private lab.
All information must be complete, or testing will not be performed.
Maternal Information (Maternal Label - optional)
To be Completed by Physician
Hospital for Delivery (in full)
Unexpected antibodies present?
Antibody(s) _____________________ Reference # ___________________
yyyy-mmm-dd
yyyy-mmm-dd
Expected Date of
Date of Birth
Delivery
Personal Health Number PHN (or Unique number if no PHN)
RhIG given this pregnancy?
Specimen collected before injection?
No Yes
Date _____________
No Yes
Mother's information must be complete when submitting Father's specimen
yyyy-mmm-dd
Personal Health Number PHN (or Unique number if no PHN)
Date of
Birth
All information must be complete (Please indicate clinic name).
Physician / Midwife
Results faxed within 72 hours of sample receipt.
Physician Name / Midwife Name
Physician Name / Midwife Name
City Prov Postal Code City Prov Postal Code
Physician Name / Midwife Name
Physician Name / Midwife Name
CLINIC NAME FAX Number Phone Number CLINIC NAME FAX Number Phone Number
Label tubes with full name, PHN (or other unique number) and date of collection.
Specimen Collection
Ensure that information on specimens EXACTLY MATCHES information on requisition.
Mother – Routine or Infertility Mother – Clinically Significant Antibody
by CBS Diagnostic
Initial & 26 weeks
When requested by CBS Diagnostic Services
Services
Draw one 6 or 7mL EDTA Draw three 6 or 7mL EDTA
Date of Collection (yyyy-mmm-dd)
Canadian Blood Services, Diagnostic Services
BC & Yukon Centre, 4750 Oak Street, Vancouver, BC, V6H 2N9
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.
For test results: Fax (604) 874-6582. Do not phone.
