Hematology Specialty Requisition

PatientPHNA lternate IdentifierDate of Birth (dd-Mon-yyyy)Last NameFirst NameGender M FPhoneAddressCity / TownProvPostal CodeLocationRequester(s)Requester Name (last, first)Copy to (last, first)Date Stamp (for lab use only)Location/Facility/Address and Location CodeLocation/Facility/Address and Location CodePhonePhoneHealthcare Provider ID / Physician CodeHealthcare Provider ID / Physician CodeCollectionDate (dd-Mon-yyyy)Time (24 hr)LocationCollector IDBill Type CPL Alberta Health Care OT Out of ProvCCO Alberta Health Care Third Party XX Pre-paidCO DynaLIFEDXPB Patient BillCo. name _____Address _____Client # _____Specimen Event TypeIA AUXILIARY IP IN PT OP OUT PT AP AMBUL HC HMCAREST STAFFEN ENVIRONWCB WORKER S COMPHISTORYH istory and object of examination: Hematology Specialty RequisitionCH-0312(Rev2020-06)Accession #HISTORYP ertinent drug history:oon Coumadin o on Heparinoon other anticoagulants (specify) _____oon Estrogen ( OCP)oon G-CSFO ther _____Physical findings:No YesSplenomegaly _____Hepatomegaly _____Lymphadenopathy _____Pregnant _____Other _____Recent Transfusions _____Laboratory Medicine and PathologyEdmonton Zone Laboratory ServicesClient Response Centre 780-407-7484 SPECIAL CO

Blood Smear & Bone Marrow Aspirate Examination Required: PC o Peripheral blood film BMPRO o: Bone marrow aspiration / biopsy (pre-book at 780-407-7484 for UAH patients or through laboratory at other hospitals) oRoutine Culture (C&S) o: T.B. o Viral o Fungal

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  Specialty, Requisition, Bone, Marrow, Hematology, Parasite, Bone marrow, Bone marrow aspirate, Hematology specialty requisition

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