Hematology Specialty Requisition

1 PatientPHNA lternate IdentifierDate of Birth (dd-Mon-yyyy)Last NameFirst NameGender M FPhoneAddressCity / TownProvPostal CodeLocationRequester(s)Requester Name (last, first)Copy to (last, first)Date Stamp (for lab use only)Location/Facility/Address and Location CodeLocation/Facility/Address and Location CodePhonePhoneHealthcare Provider ID / Physician CodeHealthcare Provider ID / Physician CodeCollectionDate (dd-Mon-yyyy)Time (24 hr)LocationCollector IDBill Type CPL Alberta Health Care OT Out of ProvCCO Alberta Health Care Third Party XX Pre-paidCO DynaLIFEDXPB Patient BillCo. name _____Address _____Client # _____Specimen Event TypeIA AUXILIARY IP IN PT OP OUT PT AP AMBUL HC HMCAREST STAFFEN ENVIRONWCB WORKER S COMPHISTORYH istory and object of examination: Hematology Specialty RequisitionCH-0312(Rev2020-06)Accession #HISTORYP ertinent drug history:oon Coumadin o on Heparinoon other anticoagulants (specify) _____oon Estrogen ( OCP)oon G-CSFO ther _____Physical findings.

2 No YesSplenomegaly _____Hepatomegaly _____Lymphadenopathy _____Pregnant _____Other _____Recent Transfusions _____Laboratory Medicine and PathologyEdmonton Zone Laboratory ServicesClient Response Centre 780-407-7484 SPECIAL COAGULATIONMUST specify anticoagulation usage F8 o Factor VIIIoOther coagulation factors(specify)_____VWFAG o Von Willebrand Factor AntigenRISTO o Ristocetin cofactorF8 INH o Factor VIII inhibitor titreAT3 o Antithrombin IIIPROTC o Protein C oon CoumadinPROTS o Protein Soon CoumadinAPCE o APC Resistance (clot-based)APCGN o APC Resistance (Factor V Leiden)PROM o Prothrombin G20210 ALUP o Lupus AnticoagulantAPA o Antiphospholipid AntibodiesDHCYS o Homocysteine (fasting _____ hr)TT o Thrombin timePTTIN o PTT InhibitorPLAGG o Platelet Aggregation (book at 780-407-7484)HITHIT o Heparin-induced thrombocytopeniaPrevious heparin exposure (past 3 months)?

3 ONo o Yes if Yes, indicate UNFH orspecific LMWH brand_____Start Date _____Stop Date _____Thrombosis while on heparin? o No o Ye sBlood Smear & bone marrow AspirateExamination Required PC o Peripheral blood filmBMPRO o bone marrow aspiration / biopsy (pre-book at 780-407-7484 for UAH patients or through laboratory at other hospitals)oRoutine Culture (C&S) o Viral o Fungal(Microbiology Requisition must be completed)Complete During ProcedureSite o Posterior Iliac Crest o Right o LeftoSternumoOther _____Performed by (name) _____Trephine biopsy length _____CytogeneticsCancer Specimens Specimen TypeBM (AP) o Karyotype, bone marrow aspirateB (AP) o Karyotype, unstimulated blood Other o Karyotype _____Indications for test _____Special HematologyG6PD o Glucose 6 Phosphate DehydrogenaseFETAL o Fetal cell stain (Kleihauer-Betke)Flow Cytometry ImmunophenotypingSpecimen TypeoBloodoBone MarrowoOther (specify)

4 _____XFACS o Lymphoma / Lymphoproliferative disorderFACS o Acute LeukemiaLMRD o Lymphoblastic Minimal Residual DiseaseTLYM o T-Lymph subsets (CD3 / 4 / 8)BTNK o B, T and NK Lymphocyte EnumerationEMAB o EMA / Osmotic Fragility (Pre-book at 780-407-7484)PNHF o PNH ScreenIndication _____Hemoglobinopathy / Malaria InvestigationHBFS o Hb F/S quantitationTHAL o Hemoglobinopathy investigationSHBS o HgB S Ethnic origin _____MAL o Malaria filmTravel history _____ Other Tests