Microbiology Requisition Scanning Label or Accession

1 20571(Rev2021-07) Microbiology RequisitionRequired Clinical InformationSuspected Organism/Diagnosis/Clinical HistoryCurrent or Recent Antibiotics/AntifungalsEye, Ear, Nose, Throat CultureUrine Throat (Acute Pharyngitis Screen, Group A Strep) Treatment failure Penicillin Allergy Mouth (Oral Candidiasis) Nasal (Staphylococcus aureus Carriage) Ear Left Right Urine Culture Source/Specimen Type midstream Urine Indwelling Catheter In/Out Catheter Other _____History (required)Symptomatic Lower urinary tract infection (UTI) Sepsis/pyelonephritis UTI in MS or Spinal Cord InjuryAsymptomatic - must specify Pregnant Prior to urologic procedure <1 month post-Renal TransplantEye (Superfi cial,Conjunctivitis) Left RightEye (Critical/Invasive) Left Right Aqueous Fluid Aspirate Biopsy Corneal Scrapings Solution Tissue Vitreous WashRespiratoryGenital TractSource/Specimen Type Sputum Other _____ Cystic Fibrosis Test Bacterial Culture Fungal Culture Mycobacterial Culture (TB/AFB)

2 Bacterial vaginosis/yeast: vaginal swab Trichomonas vaginalis screen: vaginal swab Group B Strep Pregnancy Screen: vaginal/rectal swab Penicillin Allergy Chlamydia/Gonorrhea ScreenIf pregnant: Initial Screen Rescreen Test of Cure Source Urine, fi rst catch Endocervix Urethra Vagina Rectal Throat Eye Gastrointestinal Stool Culture (Bacterial Enteric Screen/Panel) C. diffi cile TestStool for ParasitesSymptom Duration 7 days > 7 days Unknown Genital CultureSource/Specimen Type Endocervix Urethra Vagina Signifi cant History Required Puerperal Sepsis Toxic Shock Pelvic/GU Surgery Gonorrhea Culture (treatment failure) Other _____ Stool Parasite Screen.

3 Cryptosporidium/Giardia Ova & Parasite Investigation: Signifi cant history required Travel to/residence in Location developing country _____ Bloody Stool Eosinophilia Immunocompromised Other _____Wounds, Tissue, Other Superfi cial Culture ( 2cm)Site/Location Required PinwormSource/Spec Type Required Wound/Incision Abscess Ulcer Burn Bite Blood and Sterile Body FluidsBlood Blood CultureCSF If risk of CJD, must call laboratory Bacterial Culture CSF Viral Panel Fungal Culture Mycobacterial Culture (TB/AFB) Deep Culture (> 2cm)

4 Source/Spec Type Required Wound/Incision Abscess Ulcer Site/Location RequiredBody Fluid TissueTest Bacterial Culture Fungal Culture Mycobacterial Culture (TB/AFB)Site/ Location Required Source/Specimen TypeTest Bursa Synovial Prosthetic Dialysate Drain ( JP) in situ < 24h Other _____ Bacterial Culture Fungal Culture Mycobacterial Culture (TB/AFB)Other Implanted Medical Device - specify _____ Catheter Tip - specify _____ Dermatophytes - Fungus Hair Skin Nail Parasite/Worm/Arthropod Identifi cation - specify _____Infection Control Screen MRSA Screen Source/Specimen Type Nasal/Nares Groin/Inguinal Other _____Other Tests / CommentsAlberta Precision Laboratories 1-877-868-6848 Appointment Booking & Locations: - Form is used for regular and downtime use.

5 Boldand italicizedfields contain critical data elements that must be reconciled for Label or Accession # (lab only)Provider(s)PatientCollectionPHN Expiry:_____Date of Birth (dd-Mon-yyyy)Legal Last NameLegal First NameMiddle Name Alternate Identifi erPreferred Name Male Female 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 ID