Transcription of General Laboratory Requisition - Alberta Health Services
1 General Laboratory RequisitionAppointment Booking & Locations: or Alberta Precision Laboratories 1-877-868-6848 DynaLIFE Medical Labs 1-800-661-9876 or 780-451-3702 21302(Rev2021-11)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-dimero INRo Reticulocyte CountCortisol 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), ProgressiveDrug Levels/Monitoringo Ethanol Level, BloodTherapeutic Drug MonitoringDose route o Oral o IV o OtherDose Regimen _____How Long on Current Regimen?
2 _____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 _____AntibioticsGentamicin oPre oPost oInterval oOtherTobramycin oPre oPost oInterval oOtherVancomycin oPre oOtherGeneral Chemistryo Albumino Alkaline Phosphatase (ALP)o Alanine Aminotransferase (ALT)o Bilirubin, Total OR o Total and Conjugatedo Calciumo C-Reactive Protein (CRP)o Creatine Kinase (CK)o Creatinine (eGFR) o Ferritino Gamma Glutamyl Transferase (GGT)o Glucose Fasting o Glucose Gestational Diabetes Screen (GDS)o Glucose Tolerance, Gestational, 2 ho Glucose Randomo Glucose Tolerance, 2 h o Hemoglobin A1co HCG, Serum (Quantitative)Immunoglobulins.
3 O IgA oIgG o IgMo Lipaseo Magnesiumo Phosphateo Prostate Specific Antigen (PSA)o Protein Electrophoresis, Serumo Sodium (NA) o Potassium (K) o Total Proteino UrateImmunology/Serologyo Epstein Barr Serology Panelo Hepatitis A Virus Acute Serology - IgMo Hepatitis A Virus Immunity Serology - IgGo Hepatitis B Surface Antigeno Hepatitis B Surface Antibodyo Hepatitis C Virus Serology o HIV 1 and 2 Serology (Antigen and Antibody)o Mononucleosis Screeno Rheumatoid Factoro Rubella Immunity Serology - IgGo Syphilis screenCardiologyUrine Drug Testing Panelso ElectrocardiogramEdmonton ECG to be read by o Dynalife panel o Other _____Calgary See Separate ECG RequisitionReason For Request _____o Opioid Dependency Panel What is Treatment Regimen? o Buprenorphine o Methadone o Morphine o Hydromorphone o Other _____o General Toxicology Panelo Lipid Panel o Cholesterol, Total o Triglycerideso Cardiovascular Disease Risk Assessment(Framingham Risk Score) includes Lipid PanelRequired HistorySystolic Blood Pressure _____mmHgTobacco Use o Yes o No Treated for high Blood Pressure o Yes o NoDiabetic o Yes o No Chronic Kidney Disease o Yes o NoAtherosclerosis (MI, Stroke) o Yes o No First-degree relative with Cardiovascular Disease (M <55 / F <65) o Yes o NoTransfusion Medicineo Direct Antiglobulin Test (DAT)
4 O RHIG Eligibility, PrenatalType & Screen - See TM RequisitionPrenatal RBC Serology use CBS Perinatal ReqChlamydia/Gonorrheao Chlamydia/Gonorrhea ScreenIf Pregnant: o Initial Screen o Rescreen o Test of Cure Source: o Urine, first catch o Endocervix o Urethra o Vagina o Rectal o Throat o EyeUrineo Urinalysiso Pregnancy Test (HCG, Qualitative)Albumin* o Random o 24 hCreatinine o Random o 24 h Cortisol 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 FluidAdditional Testso Fluid Type _____ Source: _____Test(s) _____Miscellaneouso FIT Colorectal Cancer Screening (Age 50-74)o H.
5 Pylori Test o Hemoglobinopathy InvestigationFFFIIIIIFIIP rovider(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) For quicker access to key test results, visit.
