Government of Ontario: Ministry of Health and Long-Term Care

Laboratory Requisition
Requisitioning Clinician / Practitioner






Check (√ ) one:        







  

Sex

   





Patient’s First & Middle Names (as per OHIP Card)


Note: Separate requisitions are required for cytology, histology / pathology, ColonCancerCheck FIT test, and tests performed by Public Health Laboratory

Biochemistry

               













Child's Age   
     
     


     
      hr.       hr.
      hr.       hr.
      hr.       hr.

Hematology


Immunology





Microbiology ID & Sensitivities (if warranted)













Specimen Collection

  

Viral Hepatitis (check one only)




Specify:
   
   
   
or order individual hepatitis tests in the“Other Tests” section below

Prostate Specific Antigen (PSA)

  
Specify one below:

Vitamin D (25-Hydroxy)


Other Tests - one test per line









I hereby certify the tests ordered are not for registered in or
out patients of a hospital.