Acute Laboratory Requisition Form

1 O Routine o Stat Requisition Date Denotes a Fasting Test. Refer to Patient Instruction Fasting _____o Third Party BillClient _____Hematology/CoagulationEndocrineClin ical Informationo CBC and Differential o CBC No Differentialo D-dimer o Fibrinogeno PTT o Reticulocyte Counto INRC ortisol o Random o AM (0700-1000) o PM (1500-1800)o Estradiolo Follicle Stimulating Hormone (FSH)o Luteinizing Hormone (LH)o Parathyroid Hormone (PTH)o Progesteroneo Prolactin o Testosterone, Total o Thyroid Stimulating Hormone (TSH)o Thyroid Stimulating Hormone (TSH), ProgressiveGeneral ChemistryToxicology (Quantitative, Blood)o Albumin o Alkaline Phosphatase (ALP)o Alanine Aminotransferase (ALT)

2 O Ammoniao Anti-Neutrophil Cytoplasmic Antibody (ANCA)o Bilirubin, Total OR o Total and Conjugatedo B-Natriuretic Peptide (BNP or NT-Pro BNP)o Calcium o Complement C3o Complement C4o Creatine Kinase (CK)o Calcium, Ionizedo C-Reactive Protein (CRP)o Creatinine (eGFR)o Electrolyte Panel OR o Na o K o Cl o CO2o Ferritino Gamma Glutamyl Transferase (GGT)o Glucose, Randomo Beta hCG, QuantitativeImmunoglobulins: o IgA o IgG o IgMo Iron Overdoseo Iron and TIBCo Lactateo Lactate Dehydrogenase (LD)o Lipaseo Magnesiumo Osmolal Gapo Osmolalityo Phosphateo Total Proteino Triglycerides o Troponino Urate o Ureao Acetaminophen Level o Salicylate Levelo Ethanol Level o Alcohol Panel (Ethylene Glycol, Methanol, Iso-propanol, Acetone)Therapeutic Drug MonitoringDose route o Oral o IV o OtherDose Regimen _____How Long on Current Regimen?

3 _____Date of Last Dose or IV Complete _____Time of Last Dose or IV Complete _____ Date of Next Dose or IV Start _____ Time of Next Dose or IV Start _____o Carbamazepine o Phenytoin, Totalo Cyclosporine pre dose o Sirolimuso Cyclosporine 2 h post o Tacrolimuso Digoxin o Theophyllineo Lithium o Valproateo Phenobarbital o Other _____AntibioticsAmikacin o Pre o Post o OtherGentamicin o Pre o Post o Interval o OtherTobramycin o Pre oPost oInterval o OtherVancomycin o Pre o OtherAnticoagulanto Anti-Xa - Unfractionated Heparino Anti-Xa - LMWH o Anti-Xa - Apixabano Anti-Xa - RivaroxabanImmunology/Serologyo Hepatitis A Virus Acute serology - IgMo Hepatitis A Virus Immunity serology - IgGo Hepatitis B Surface Antigeno Hepatitis B

4 Surface Antibodyo Hepatitis C Virus serology o HIV 1 and 2 serology (Antigen and Antibody)o Mononucleosis Screeno Syphilis screenUrineo Urinalysiso Pregnancy Test (HCG, Qualitative)o OsmolalityAlbumin* o Random o 24 hCalcium* o Random o 24 h Creatinine o Random o 24 h Cortisol o 24 hElectrolyte Panel o Random o 24 h Protein Total* o Random o 24 h Protein Electrophoresis o Random o 24 h *includes creatinine ratioo Creatinine Clearance 24h Ht_____ cm Wt_____ kg24H Urine Total Volume_____Start Date_____ Start Time_____End Date _____ End Time_____Sterile Body FluidsFluid Type.

5 O CSF OR o Other Body FluidSource: _____Test(s): _____Acute Laboratory RequisitionAppointment Booking & Locations: or Alberta Precision Laboratories 1-877-868-6848 DynaLIFE Medical Labs 1-800-661-9876 or 780-451-370221647(Rev2022-04)FIProvider( s)PatientCollectionPHN Expiry: _____Date of Birth (dd-Mon-yyyy)Legal Last NameLegal First NameMiddle NameAlternate IdentifierPreferred Nameo Male o Femaleo Non-binary o Prefer not to disclosePhoneAddressCity/TownProvPostal CodeAuthorizing Provider Name (last, first, middle)Copy to Name (last, first, middle)Copy to Name (last, first, middle)AddressPhoneAddressAddressCC Provider IDCC Submitter IDLegacy IDPhonePhoneClinic NameClinic NameClinic NameDate (dd-Mon-yyyy)Time (24 hr)LocationCollector IDScanning Label or Accession # (lab only)Important - Form is used for regular and downtime use.

6 Bold and italicized fields contain critical data elements that must be reconciled for Tests