Transcription of General Test Requisition
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General Test Requisition
Date received PHOL No. General Test Requisition Public Health Unit Outbreak No. 2 - Patient InformationPatient Address 1 - Submitter Courier Code Provide Return Address: NameAddressCity & Province Postal Code Clinician Initial / Surname and OHIP / CPSO Number Tyyyy / mm / ddyyyy / mm / dd Health No. Patient s Last Name (per OHIP card) Date of Birth: First Name (per OHIP card) SexSubmitter Lab Phone Code ALL Sections of this Form MUST be Completed Medical Record Doctor Information Public Health Investigator InformationName: Tel:Lab/Clinic Name: Fax:CPSO #:Address.
Date received PHOL No. General Test Requisition Patient Setting Public Health Unit Outbreak No. 2 - Patient Information
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