Transcription of Laboratory Services Vitamin D (25 …
1 Scanning Label or Accession # (lab only)Provider(s)PatientCollectionPHNE xpiry: _____Date of Birth (dd-Mon-yyyy)Legal Last NameLegal First NameAlternate Identifi erMiddle NamePreferred Name Male Female X Non-binary/Prefer not to disclosePhoneAddressCity/TownProvPostal CodeAuthorizing Provider Name (last, fi rst, middle)Copy to Name (last, fi rst, middle)Copy to Name (last, fi rst, middle)AddressPhoneAddressAddressCC Provider IDCC Submitter IDLegacy IDPhonePhoneClinic NameClinic NameClinic NameDate (dd-Mon-yyyy)Time (24 hr)LocationCollector IDLaboratory Services Vitamin D (25- hydroxy ) RequisitionVitamin D testing may only be ordered using this (Rev2020-06)Testing CriteriaAll medically necessary 25- hydroxy Vitamin D testing will be supported by Alberta Health. Any 25- hydroxy Vitamin D testing that does not meet the testing criteria listed below will be deemed not medically necessary, and will not be performed. (Check all that are appropriate for your patient) oMetabolic bone diseasesoAbnormal blood calciumoMalabsorption syndromes (celiac disease, small intestine surgery, anticonvulsant agents)oChronic renal diseaseoChronic liver diseasePhysician SignatureFor additional information, please refer to the 2014 Vitamin D Clinical Practice Guidelines on the TOP website located at: For Laboratory hours of operation and contact information please go to
