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Serology and Molecular Testing Requisition form

20676(Rev2021-05)RequestorPatientPHNA lternate IdentifierDate of Birth (yyyy-Mon-dd)Last NameFirst NameMiddleGenderPhoneAddressCity/TownPro vPostal CodeLocationRequestor Name (last, first)Location/Facility/AddressPhoneHeal thcare Provider IDCopy to (last, first)Location/Facility/AddressPhoneHeal thcare Provider IDSerology and Molecular Testing RequisitionEdmonton Site 8440-112 St. T6G 2J2 Phone Fax Site 3030 Hospital Dr NW T2N 4W4 Phone Fax # (lab only)Provincial Laboratory for Public Healthn Consult the Site Virologist/Microbiologist-on-Call listed above for STAT requests, and when specified in the Guide to Servicesn See the Guide to Services ( ) for information on sample type, transport and Testing n For Zoonotic infections (eg.)

o Epstein-Barr virus EBV PCR o HBV DNA HBV QUANT o HCV RNA HCV QUANT ... HBsAg Hepatitis B surface antigen Screening for acute or chronic infection ... HBV DNA (hepatitis B) Assessment of viremia or treatment monitoring EDTA blood x 2 Remote users - send Plasma

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  Screening, Virus, Hepatitis b, Hepatitis, Infections

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Transcription of Serology and Molecular Testing Requisition form

1 20676(Rev2021-05)RequestorPatientPHNA lternate IdentifierDate of Birth (yyyy-Mon-dd)Last NameFirst NameMiddleGenderPhoneAddressCity/TownPro vPostal CodeLocationRequestor Name (last, first)Location/Facility/AddressPhoneHeal thcare Provider IDCopy to (last, first)Location/Facility/AddressPhoneHeal thcare Provider IDSerology and Molecular Testing RequisitionEdmonton Site 8440-112 St. T6G 2J2 Phone Fax Site 3030 Hospital Dr NW T2N 4W4 Phone Fax # (lab only)Provincial Laboratory for Public Healthn Consult the Site Virologist/Microbiologist-on-Call listed above for STAT requests, and when specified in the Guide to Servicesn See the Guide to Services ( ) for information on sample type, transport and Testing n For Zoonotic infections (eg.)

2 Mosquito-borne, tick-borne) use form 20087 Zoonotic Testing Requisition ( )Specimen/Type Source - SpecifyDate Collected (yyyy-Mon-dd)Time (24 hr)LocationCollector IDOutbreak (EI) if applicable (yyyy-###) Bloodo Bloodo Bone Marrowo Cord BloodFluido CSFo Auger Suctiono Bronchoalveolar Lavage (BAL)o Eye (Aqueous)o Eye (Vitreous)o Nasopharyngealo UrineSwab o Buccalo Cervicalo Eye (specify)_____o Lipo Lesion (specify) _____o Moutho Nasopharyngealo Rectalo Throato UrethralTissueo Autopsy (specify) _____o Biopsy (specify) _____Other o Stool o Other (specify)_____Viral SerologyParasite SerologyMolecular Detection (NAT) o CMV IgG CMV IGGo EBV Panel EBV ABo HSV IgG HSV IGGo Measles IgG MEAS IGGo Mumps IgG MUMPS IGGo Parvovirus B19 IgG PARVO IGGo Rubella IgG RUB IGG PROVo Varicella zoster IgG VZV IGGH epatitis Ao HAV IgG HAV IGG PROVo HAV IgM HAV IGM PROVH epatitis Bo HBsAg HBV SAG PROVo HBsAb HBV SAB PROVo HBc IgM Ab HBC IGM PROVo HBc Total Ab HBC TOT PROVo HBe Ag HBEAG PROVo HBe Ab HBEAB PROVH epatitis Co HCV Serology HCV ABo Strongyloides STRONGo Toxoplasma TOXO IGGo Bordetella Panel BP

3 PCRo CSF Viral Panel CSF PANELo Entero/Parechovirus EV PEV PCRo Eye Viral Panel EYE PANELo Gastroenteritis Viral Panel GI PANELo Herpes simplex virus HS VZ PCRo Measles virus MEAS PCRo Mumps virus MUMPS PCRo Respiratory Pathogen Panel o Varicella zoster virus HS VZ PCRo Syphilis SYPH PCRB acterial Serologyo Brucella BRUCo Diphtheria antitoxin DIPHTHo Mycoplasma pneumoniae MPNEU IGMo Syphilis SYPH PROVo Tetanus antitoxin TET ATOXo CMV IgM CMV IGMo Measles IgM MEAS IGMo Mumps IgM MUMPS IGMo Parvovirus B19 IgM PARVO IGMo Rubella IgM RUB IGM PROVF ungal SerologyRestricted Molecular Testingo Blastomyces BLAST IDo Coccidioides o Cryptococcal Antigeno Galactomannan o Histoplasma HISTO IDo Adenovirus AD PCRo BK virus BKV PCRo Cytomegalovirus CMV PCRo Epstein-Barr virus EBV PCRo HBV DNA HBV QUANTo HCV RNA HCV QUANTo HIV QUAL HIV QUALo HIV Viral Load HIV QUANTo JC virus HPOLYVIR PCRo HIV Serology HIV ABSpecify Other Serology and Molecular

4 TestsProvide Clinical History or Reason for Testing below - Testing will NOT proceed if this section is incompleteReason for TestingList Countries visited within past 3 months of symptom onset OR provide relevant travel history o No TravelSymptoms (Check all that apply)o Fever o Rash (type) _____o Gastrointestinal o Respiratory (specify) _____o Neurologic o Other (specify) _____o Polyarthritis Date of return (yyyy-Mon-dd)Relevant immunizations and datesDate of onset OR Duration of symptomsImmunocompromised o No o Yes (details) _____ Do Not Submit this pageGuidance Notes The Tables and notes below provide supplementary information on the tests, clinical indications, sample types and transport medium.

5 Consult the Provincial Laboratory (ProvLab) Guide to Services @ for comprehensive Serology :As IgM antibody Testing can be helpful in diagnosing acute symptomatic infections , Testing WILL ONLY BE PERFORMED whensymptoms and date of onset of illness are provided. Testing for IgM antibody in asymptomatic patients can result in false positives. IgM antibody can persist for long periods; consult the Virologist-on-Call for helpwith and Fungal Serology :Travel history, symptoms and date of onset or duration of illness are MANDATORY when sending samples to the National Reference Centre for Parasitology or other Reference Laboratories for & Body fluid exposure request:panel comprises of the following tests: HBsAg, anti-HBs, HIV and HCV serologies Molecular Detection [Nucleic Acid Testing (NAT)].

6 Test Usual Specimen(s) Comments Bordetella Panel Nasopharyngeal swab ONLY in Regan-Lowe medium (Black charcoal based medium) Testing includes Bordetella pertussis CSF Viral panel Minimum volume = mL CSF HSV/VZV and entero/parechovirus Testing Entero/parechovirus Stool in sterile container (NO preservative or transport medium), nasopharyngeal, throat or lesion swab in Universal Transport Medium Detection of polio and non-polio enteroviruses causing acute flaccid paralysis send stool and NP swab Some enteroviruses, , coxsackievirus, cause vesicular skin lesions, in these cases a swab from the lesion can be useful. Gastroenteritis Viral panel Stool in sterile container (NO preservative or transport medium) For outbreaks obtain an EI number through the zone Medical Officer of Heath or designate Herpes simplex & varicella zoster Lesion swab in Universal Transport Medium Respiratory Pathogen Panel Nasopharyngeal swab (NP)

7 In Universal Transport Medium or respiratory aspirates in a sterile container Primarily for influenza virus Testing For outbreaks obtain an EI number through the zone Medical Officer of Health or designate Measles Nasopharyngeal swab in Universal Transport Medium AND urine in sterile container Blood for measles Serology MUST notify zone Medical Officer of Health of suspected cases Mumps Buccal swab in Universal Transport Medium Blood for mumps Serology Syphilis Lesion swab in Universal Transport Medium Also send blood for syphilis Serology Testing can be combined with herpes simplex detection Restricted Molecular Testing : Tests listed below are for diagnosis and monitoring in transplant and immunocompromised patients or to help clarify the diagnosis in some complex clinical scenarios.

8 When requesting, MUST provide clinical indication or reason for Testing . hepatitis Markers abbreviations and usual indications for Testing HAV IgG hepatitis A IgG Past infection or vaccination response HAV IgM hepatitis A IgM Recent infection HBsAb Antibody to hepatitis B surface antigen Immunity status HBsAg hepatitis B surface antigen screening for acute or chronic infection HBc Total Ab Total antibody to hepatitis B Exposure at undetermined time HBc IgM Ab IgM antibody to HBV core Recent infection HBe Ab OR HBe Ag Antibody to HBV e antigen OR HBV e antigen Prognostic markers for HBV infection Test/ virus Usual Indications Usual Specimen HCV RNA ( hepatitis C)

9 Assessment of viremia or treatment monitoring Serum (Gold Top Vacutainer) HIV QUAL Diagnosis of HIV EDTA blood x 2 (Lavender top vacutainer) Remote users - send Plasma Preparation tubes (PPT) x 2 HIV QUANT Treatment monitoring For Calgary and South Zones, orderable is MQHI through Calgary Lab Services; for the other zones Testing is performed by ProvLab HIV proviral DNA Primarily to diagnose HIV in the newborn Sent to HIV Reference Lab Monday to Thursday. Do NOT send samples on Fridays, weekends or statutory holiday, to allow for shipping. EDTA blood HBV DNA ( hepatitis B) Assessment of viremia or treatment monitoring EDTA blood x 2 Remote users - send Plasma Preparation tubes (PPT x 2) Adenovirus, Cytomegalovirus, Epstein- Barr virus Primarily for monitoring in transplant/significantly immunocompromised patients EDTA blood JC virus As above CSF BK virus As above EDTA blood & Urine Guidance Notes The Tables and notes below provide supplementary information on the tests, clinical indications, sample types and transportmedium.

10 Consult the Provincial Laboratory (ProvLab) Guide to Services @ for comprehensive information. Viral Serology : As IgM antibody Testing can be helpful in diagnosing acute symptomatic infections , Testing WILL ONLY BE PERFORMED when symptoms and date of onset of illness are provided. Testing for IgM antibody in asymptomatic patients can result in false positives. IgM antibody can persist for long periods; consult the Virologist-on-Call for help with interpretations. Parasite and Fungal Serology : Travel history, symptoms and date of onset or duration of illness are MANDATORY when sending samples to the National Reference Centre for Parasitology or other Reference Laboratories for Testing .


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