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www.forms.ssb.gov.on.ca

Specimen CollectionxBiochemistryxHematologyxViral Hepatitis (check one only)Glucose Random FastingCBCA cute HepatitisHbA1 CProthrombin Time (INR)Chronic HepatitisCreatinine (eGFR)ImmunologyImmune Status / Previous ExposureSpecify: Hepatitis A Hepatitis B Hepatitis Cor order individual hepatitis tests in the Other Tests section belowUric Acid Pregnancy Test (Urine)SodiumMononucleosis ScreenPotassiumRubellaALTP renatal: ABO, RhD, Antibody Screen(titre and ident. if positive)Alk. PhosphataseProstate Specifi c Antigen (PSA)BilirubinRepeat Prenatal AntibodiesTotal PSA Free PSAI nsured Meets OHIP eligibility criteriaUninsured Screening: Patient responsible for paymentAlbuminMicrobiology ID & Sensitivities(if warranted)Lipid Assessment (includes Cholesterol, HDL-C, Triglycerides, calculated LDL-C & Chol/HDL-C ratio; individual lipid tests may be ordered in the Other Tests section of this form )CervicalVaginalVitamin D (25-Hydroxy)Albumin / Creatinine Ratio, UrineVaginal / Rectal Group B StrepInsured - Meets OHIP eligibility criteria:osteopenia; osteoporosis; rickets;renal disease; malabsorption syndromes;medicatio

Specimen Collection x Biochemistry x Hematology x Viral Hepatitis (check one only) Glucose Random FastingCBCAcute Hepatitis HbA1C Prothrombin Time (INR) Chronic Hepatitis

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1 Specimen CollectionxBiochemistryxHematologyxViral Hepatitis (check one only)Glucose Random FastingCBCA cute HepatitisHbA1 CProthrombin Time (INR)Chronic HepatitisCreatinine (eGFR)ImmunologyImmune Status / Previous ExposureSpecify: Hepatitis A Hepatitis B Hepatitis Cor order individual hepatitis tests in the Other Tests section belowUric Acid Pregnancy Test (Urine)SodiumMononucleosis ScreenPotassiumRubellaALTP renatal: ABO, RhD, Antibody Screen(titre and ident. if positive)Alk. PhosphataseProstate Specifi c Antigen (PSA)BilirubinRepeat Prenatal AntibodiesTotal PSA Free PSAI nsured Meets OHIP eligibility criteriaUninsured Screening: Patient responsible for paymentAlbuminMicrobiology ID & Sensitivities(if warranted)Lipid Assessment (includes Cholesterol, HDL-C, Triglycerides, calculated LDL-C & Chol/HDL-C ratio; individual lipid tests may be ordered in the Other Tests section of this form )CervicalVaginalVitamin D (25-Hydroxy)Albumin / Creatinine Ratio, UrineVaginal / Rectal Group B StrepInsured - Meets OHIP eligibility criteria:osteopenia; osteoporosis; rickets;renal disease; malabsorption syndromes;medications affecting vitamin D metabolismUninsured - Patient responsible for paymentUrinalysis (Chemical)Chlamydia (specify source):Neonatal Bilirubin:GC (specify source):Child s Age: days hoursSputumClinician/Practitioner s tel.

2 No. ( )ThroatOther Tests - one test per linePatient s 24 hr telephone no. ( )Wound (specify source):Therapeutic Drug Monitoring:UrineName of Drug #1 Stool CultureName of Drug #2 Stool Ova & ParasitesTime Collected #1 hr.#2 Swabs / Pus (specify source):Time of Last Dose #1 hr.#2 of Next Dose #1 hr.#2 Occult Blood Test (FOBT) (check one) FOBT (non CCC) ColonCancerCheck FOBT (CCC) no other test can be ordered on this formLaboratory Use OnlyTime DateMinistry of Healthand Long-Term CareLaboratory RequisitionRequisitioning Clinician / PractitionerLaboratory Use OnlyNameAddressClinician/Practitioner NumberAdditional Clinical Information ( diagnosis)Note: Separate requisitions are required for cytology, histology / pathology and tests performed by Public Health LaboratoryPatient s Last Name (as per OHIP Card)Patient s First & Middle Names (as per OHIP Card)Patient s Address (including Postal Code)Copy to.

3 Clinician/PractitionerLast NameI hereby certify the tests ordered are not for registered in or out patients of a Signature4422-84 (2013/01) Queen s Printer for Ontario, 20137530-4581 DateAddressFirst Name24 hour clockyyyy/mm/ddOHIP/InsuredThird Party / UninsuredWSIBMFC heck ( ) one:Province Other Provincial Registration NumberPatient s Telephone Contact NumberCPSO / Registration NumberVersionDate of BirthService DateyyyyyyyymmmmddddSexClinician/Practit ioner s Contact Number for Urgent Results()()Specify one below.


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