Transcription of Mobile Collection Services Requisition
1 20884 (Rev 2020-12) Mobile CollectionCollection Services provided to patients outside of lab Collection centres. To be considered eligible for this service, patients must meet at least one of the following criteria: o Has had a recent hospitalization and/or surgery that restricts their travel outside the home temporarily (maximum 4 weeks). Specify reason _____Hospital discharge date (dd-Mon-yyyy) _____ o Has medical restrictions and/or health limitations and/or is physically unable to attend appointments or participate in other activites outside their home. Specify reason patient is unable to attend laboratory Collection location _____o Resides in a secured or designated supportive living enviroment ( DSL4, DSL4D).
2 Scheduling Requirements Note: Mobile Collections not available in all communitiesRequested Start: Week of _____(service date will be determined by patient location)FrequencyMaximum DurationRequested DurationDoes patient have an existing Mobile Order? o No o Yes. If yes: o Add to existing order or next scheduled Collection o Replace existing order(s) o Schedule Extra Collection (dd-Mon-yyyy) _____o Once onlyOnceo 2 times per week2 weeks (M/Th or Tu/F)o 3 times per week2 weeks (M/W/F)o Weekly12 weekso Every 2 weeks26 weeksOffice Use Only o Monthly1 yearDate received (dd-Mon-yyyy)Order expiry date (dd-Mon-yyyy)o Every 3 months1 yearTest RequiredTherapeutic Drug Monitoringo Alanine Aminotransferase (ALT)o Lipid PanelDose Route o Oral o IV o Othero Albumino MagnesiumHow long on current dose regimen?
3 O Alkaline Phosphatase (ALP)o Thyroid Stimulating Hormone (TSH)Date of last dose (dd-Mon-yyyy) (or IV Complete)o Bilirubin, Totalo Thyroid Stimulating Hormone (TSH) ProgressiveTime of last dose (hh:mm) (or IV Complete)o Calciumo UrateDate of next dose (dd-Mon-yyyy) (or IV Start)o CBC and Differentialo Urine Albumin o randomo Carbamazepineo CBC no Differentialo Urinalysiso Cyclosporineo Creatinine (eGFR)Additional Tests Not Listedo Digoxino Creatine Kinase (CK)o GentamicinElectrolytes o Na o K o Phenobarbitalo Ferritino Lithiumo Gamma Glutamyl Transferase (GGT)o Phenytoin, Totalo Glucose randomo Tacrolimuso hemoglobin A1c (max 1 x / 3 months)o Valproateo INRo VancomycinZoneFax RequisitionPhoneZoneFax RequisitionPhoneCalgary403-777-5222403-7 70-3351 North, Grande Prairie780-532-2477 (Home Care)
4 Call lab directlyCentral, Red Deer403-343-4811403-343-4749 North, All OtherCall lab directlyCentral, All OtherCall lab directlySouth, Lethbridge403-388-6068403-388-6057 Edmonton/DynaLIFE780-452-5294780-453-944 0 South Medicine Hat403-502-8284403-502-8638 Lloydminster/DynaLIFE780-452-5294780-453 -9440 South, All OtherCall lab directlyFor Mobile Collections Detailed information go to: Healthcare ProvidersMobile Collection Services RequisitionScanning Label or Accession # (lab only)Provider(s)PatientCollectionPHN Expiry: _____Date of Birth (dd-Mon-yyyy)Legal Last NameLegal First NameMiddle NameAlternate IdentifierPreferred Nameo Male o Femaleo X Non-binary/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 ID
