Laboratory Use Only
Name Address Clinician/Practitioner Number CPSO / Registration No.
Additional Clinical Information (e.g. diagnosis)
Copy to: Clinician/Practitioner
Last Name First Name Address
Clinician/Practitioner’s Contact Number for Urgent Results Service Date (yyyy/mm/dd) Health Number Health Number Version
M F
Date of Birth (yyyy/mm/dd) Province Other Provincial Registration Number Patient’s Telephone Contact Number Patient’s Last Name (as per OHIP Card)
First Name Middle Names
Patient’s Address (including Postal Code)
Note: Separate requisitions are required for cytology, histology / pathology, ColonCancerCheck FIT test, and tests performed by Public Health Laboratory
Glucose Glucose Random GlucoseFasting HbA1C Creatinine (eGFR) Uric Acid Sodium Potassium ALT Alk. Phosphatase Bilirubin Albumin 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) Albumin / Creatinine Ratio, Urine Urinalysis (Chemical) Neonatal Bilirubin: Child's Age, Clinician/Practitioner's tel. no., Patient’s 24 hr telephone no. Child's Age Child's Age days Child's Age hours Clinician/Practitioner's tel. no. Patient’s 24 hr telephone no. Therapeutic Drug Monitoring: Name of Drug #1, Name of Drug #2, Time Collected #1, Time Collected #2, Time of Last Dose #1, Time of Last Dose #2 Name of Drug #1 Name of Drug #2 Time Collected #1 hr. Time Collected #2 hr. Time of Last Dose #1 hr. Time of Last Dose #2 hr. Time of Next Dose #1 hr. Time of Next Dose #2 hr.
CBC Prothrombin Time (INR)
Pregnancy Test (Urine) Mononucleosis Screen Rubella Prenatal: ABO, RhD, Antibody Screen (titre and ident. if positive) Repeat Prenatal Antibodies
Cervical Vaginal Vaginal / Rectal – Group B Strep Chlamydia Chlamydia (specify source): GC GC (specify source): Sputum Throat Wound Wound (specify source): Urine Stool Culture Stool Ova & Parasites Other Swabs/Pus 1. Other Swabs/Pu (specify source): 2. Other Swabs/Pu (specify source):
Time Date
Acute Hepatitis Chronic Hepatitis Immune Status / Previous Exposure Specify: Immune Status / Previous Exposure: Specify Hepatitis A Immune Status / Previous Exposure: Specify Hepatitis B Immune Status / Previous Exposure: Specify Hepatitis C or order individual hepatitis tests in the“Other Tests” section below
Total PSA Free PSA Specify one below: Specify one below: Insured – Meets OHIP eligibility criteria Specify one below: Uninsured – Screening: Patient responsible for payment
Insured - Meets OHIP eligibility criteria: osteopenia; osteoporosis; rickets; renal disease; malabsorption syndromes; medications affecting vitamin D metabolism Uninsured - Patient responsible for payment
Line 1 Line 2 Line 3 Line 4 Line 5 Line 6 Line 7 Line 8 Line 9
Clinician/Practitioner Signature Date