Transcription of Serology and Molecular Testing Requisition form
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Serology and Molecular Testing Requisition form
20676(Rev2021-05)RequestorPatientPHNA lternate IdentifierDate of Birth (yyyy-Mon-dd)Last NameFirst NameMiddleGenderPhoneAddressCity/TownPro vPostal CodeLocationRequestor Name (last, first)Location/Facility/AddressPhoneHeal thcare Provider IDCopy to (last, first)Location/Facility/AddressPhoneHeal thcare Provider IDSerology and Molecular Testing RequisitionEdmonton Site 8440-112 St. T6G 2J2 Phone Fax Site 3030 Hospital Dr NW T2N 4W4 Phone Fax # (lab only)Provincial Laboratory for Public Healthn Consult the Site Virologist/Microbiologist-on-Call listed above for STAT requests, and when specified in the Guide to Servicesn See the Guide to Services ( ) for information on sample type, transport and Testing n For Zoonotic infections (eg.)
o Epstein-Barr virus EBV PCR o HBV DNA HBV QUANT o HCV RNA HCV QUANT ... HBsAg Hepatitis B surface antigen Screening for acute or chronic infection ... HBV DNA (hepatitis B) Assessment of viremia or treatment monitoring EDTA blood x 2 Remote users - send Plasma
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