Transcription of Standing Out-Patient Laboratory Requisition
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ORDERING PRACTITIONER: ADDRESS, PHONE, MSP PRACTITIONER NUMBERLOCUM 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 NUMBERICBC/WorkSafeBC NUMBERLAST NAME OF PATIENTFIRST NAME OF PATIENTDOBYYYY MM DDSEX M FOTHER CONTACT NUMBER OF PATIENTP regnant? YES NO Fasting? h pcADDRESS OF PATIENTPROVINCECITY/TOWNPRIMARY CONTACT NUMBER OF PATIENTCopy to PRACTITIONER/MSP Practitioner Number:Copy to PRACTITIONER/MSP Practitioner Number:DIAGNOSISHEMATOLOGYURINE TESTSCHEMISTRY Hematology profile On Anticoagulant?
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 ... CURRENT MEDICATIONS/DATE AND TIME OF LAST DOSE COLLECTOR INSTRUCTIONS TO PATIENTS (See reverse) ... provide diagnosis. Monitor thyroid replacement ...
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