Transcription of COVID-19 Test Requisition (Provincial)
1 21823(Rev2021-07)Scanning Label or Accession # (lab only)Edmonton Site 8440-112 St. T6G 2J2 Phone Fax Site 3030 Hospital Dr NW T2N 4W4 Phone Fax Full link of location codes: Consult the Site Virologist/Microbiologist-on-Call listed above for STAT requests, and when specifi ed in the Guide to Services See the Guide to Services: information on sample type, transport and testing COVID-19 Test Requisition (Provincial)Provider(s)PatientPHN Date of Birth (dd-Mon-yyyy)Legal Last NameLegal First NameMiddleAlternate Identifi erPreferred Name Male Female Non-binary Prefer not to disclosePhoneAddressCity/TownProvPostal CodeAuthorizing Provider NameCopy to Name (last, fi rst, middle)Copy to Name (last, fi rst, middle)Address PhoneAddressAddressCC Provider IDMillennium IDSunquest IDPhonePhone Prov_____ Expiry_____Specimen/Type Source - SpecifyDate Collected (dd-Mon-yyyy)Time (24 hr)
2 LocationCollector IDOutbreak (EI) if applicable (yyyy-###) Specify Other Serology and Molecular TestsFluid Bronchoalveolar Lavage (BAL) Nasopharyngeal Aspirate Endotracheal SuctionSwab Nasopharyngeal Throat COVID-19 only COVID-19 /Respiratory Pathogen PanelProvide Clinical History or Reason for Testing below - Completion of this section is requiredReason for Testing (check one) Symptomatic AsymptomaticClose Contact? Yes NoList Countries visited within past 3 months of symptom onset OR provide relevant travel history No TravelDate of onset of symptoms (dd-Mon-yyyy)Immunocompromised No Ye s(details)_____Date of return (dd-Mon-yyyy)Relevant immunizations/datesConsentContact Preference for COVID-19 Results: Text Automated Call Phone call from AHS Phone number: Health Care Worker?
3 Yes No Health Care Worker or Resident of Long Term Care/Designated Supported Living Facility? Yes No If yes, specify below Full Facility NameLocation Code - Required (see link above for list of Codes)City or Tow
