Transcription of DIAGNOSTIC CYTOLOGY REQUISITION NAME (FIRST)
1 600 West 10th Avenue PATIENT DEMOGRAPHICS. Vancouver, BC, Canada V5Z 4E6 Enter data manually, addressograph, or affix label Tel.: 604-877-6000 x 2101. Fax: 604-873-5384 NAME (LAST). DIAGNOSTIC CYTOLOGY REQUISITION NAME (FIRST). NOTE:Each specimen/part type must have a separate fully completed REQUISITION . BIRTH DATE (DD/MM/YYYY). All specimens, requisitions and slides must be labelled. Lack of/or unclear information will result in a delay or failure of processing. PHSA Labs are not responsible for unlabelled specimens. CARE CARD NUMBER (PHN). Number Of BCCA NUMBER. Specimen Collection Date Slide(s). FIXED SEX M F OTHER Specify STAT Specimen Fixed: No Yes Number Of Send Reports To: DOCTOR MSC#. Type of Fixative: Slide(s). UNFIXED. Doctors Name and Address: Office, Clinic or Hospital SPECIMEN TYPE: Respiratory SPUTUM. Specific Lobe BRONCHIAL WASH L R. BRONCHIAL BRUSH L R. BRONCHOALVEOLAR LAVAGE L R. EBUS Lymph Node SPECIFY SITE: Urinary Send Copy To: URINE - VOIDED ILEAL CONDUIT.
2 MSC# Name: URINE - CATHETERIZED URETER L R. MSC# Name: URINE - CYSTOSCOPY RENAL PELVIS L R. OTHER SPECIFY SITE: MSC# Name: Fluids Previous Malignancy: YES NO. CEREBROSPINAL FLUID. DATE: TYPE: PLEURAL FLUID L R CLINICAL. PERITONEAL FLUID WASH DATA: Radiation Therapy: YES DATE: PERICARDIAL FLUID Chemotherapy: YES DATE: SPECIFY. JOINT FLUID L R SITE: CLINICAL INFORMATION: Adequate clinical information is essential for accurate cytological interpretation. Fine Needle Aspirate L R SPECIFY. BREAST. SITE: THYROID L R Isthmus OTHER SPECIFY. L R. SITE: Other ANAL - RECTAL. L R LAB USE ONLY: NIPPLE DISCHARGE. SPECIFY PAP MGG. OTHER SITE: OTHER CB REQUISITION LABEL. Print Form Reset Form THIN TOTAL.
