REQ9012PSC 2018-03-01

FASTING HOURS (PC): # OF TUBES COLLECTED: TUBE TYPE: ACCESSION NUMBER:

£ Appointment £ Walk-In £ Specimen Drop Off

Arrival Time: ________ ____________ Initials __________

MOST COMMONLY ORDERED TESTS

CBC £ CBC includes Diff.PT £ INR (Prothrombin Time)U £ Urinalysis (Includes Microscopic

as per Protocol)HBA1C £ Hemoglobin A1cCREA £ Creatinine (Serum or Plasma)EP £ Electrolytes (Na, K,Cl)LDL £ �Lipid�profile

(Fasting not required by lab)

ALT £ Alanine AminotransferaseFERR £ Ferritin

COAGULATION

PTT £ PTT

FLUID ANALYSIS

Fluid Type _________________________________Volume ___________________________________

£ Cell Count£ Differential£ Protein & Glucose£ Crystals (Synovial Fluid Only)

PREGNANCY/FERTILITY

________________ wks gestation

UBHCG £ Beta HCG (Urine)BHCG £ Beta HCG (Plasma or Serum)GESTSC £ Gest. Diabetes Screen (50g)GTTP £ Glucose Tolerance (75g)

(See page 2) Fasting Required Call 403-770-5136 to book

SYP £ Syphilis AntibodiesPVAS £ Exam for Sperm - Post Vas

Collection Date: __________ Time: ____:____

MATSC £ Quad Screen (2nd Trimester)* *Complete AHS Form CH-1247

CHEMISTRY (SERUM OR PLASMA)

ALB £ AlbuminALP £ Alkaline PhosphataseBILTD £ Bilirubin - Total & DirectBILT £ Bilirubin - Total OnlyCA £ CalciumCL £ ChlorideCHOL £ Cholesterol - TotalCRP £ C-Reactive ProteinCK £ Creatine KinaseGGT £ Gamma Glutamyl TransferaseGLUF £ Glucose - Fasting

(Fasting required)

GLU £ Glucose RandomGTTNP £ Glucose Tolerance Non-Preg (75g)

(Fasting Required) Call 403-770-5136 to book

GLUMR £ Glucose Meter Check Meter Type and ________________ _________ mmol/L (Lab Use Only)

IRN £ Iron/TIBCLD £ Lactate DehydrogenaseLIP £ LipaseMG £ MagnesiumPHOS £ PhosphateSPE £ Protein ElectrophoresisTP £ Protein - TotalPSA £ PSATNT £ TroponinURA £ UrateUREA £ Urea

URINE DRUG SCREEN

UDSR £ Drugs of Abuse Screen (See CLS Website)

FDSU £ Drug Screen Comprehensive Requires History Form PX4162 (See CLS Website)

DRSCMISC £ Drugs of Abuse Screen Non-Medical Patient Paid (Chain of Custody) Call 403-770-5136 to Book

Specify Panel _____ ________ ___________

PROTEINS/SEROLOGY

IMMGLOB £ IgG, IgA, IgMMONOT £ MonotestRF £ Rheumatoid FactorRUBG £ Rubella Immune Status IgG

(Non-Pregnant)

ENDOCRINE

ESTRAD £ Estradiol (Non-Pregnant)FSH £ FSHLH £ LHTSH £ TSH

ACTIVE HEPATITIS

HEPSC £ Acute Hepatitis Screen (ALT, Anti-HAV, IGM, HBsAg)

HBSAG £ Hepatitis B Surface AntigenAHAVM £ Anti-HAV IgM

HEPATITIS IMMUNE STATUS

AHAVT £ Anti-Hepatitis A Virus, IgGAHBS £ Hepatitis B Surface Antibody

CHEMISTRY (URINE)

Height and weight required for all Creatinine Clearance orders

Lab Use Only

Start End

Time ______:______ ______:______

Date _____________ _____________

Urine Volume mL ________ _________________

UMALB £ Albumin Creatinine RatioUCAD £ CalciumUCORD £ CortisolU24H £ CreatinineCREACL £ Creatinine Clearance

Height __________ cm Weight __________kgU24MALB £ Albumin (24 hr)UTPD £ Protein (24 hr)UPED £ Protein Electrophoresis (24 hr)

THERAPEUTIC DRUG MONITORING

Last Dose: Time _____:____ Date: __________

£ Pre £ Post £ RandomRoute: £ Oral £ IV £ Other

Dose Regimen __________________________Dose Duration __________________________

CYCLO £ CyclosporinDIG £ Digoxin

(Collect 8 hours after last dose)CARB £ CarbamazepineLI £ LithiumPTN £ PhenytoinSIRO £ SirolimusTACRO £ TacrolimusVALP £ Valproate

SPECIAL HEMATOLOGY

HBELEC £ Hemoglobinopathy/Thalassemia Screen (includes Hb S Quantitation)

Ethnic background: ________ _________________

Prenatal: Yes £ No £SICKLES £ Sickle Cell Screen

MISCELLANEOUS

HIV £ HIV Serology ProvLab (Medical Reasons)

HIVDSC £ HIV Serology CLS (Patient Paid: Visa, Insurance, Immigration, Company Use)

FIT £ Colorectal Cancer Screening (Asymptomatic 50-74 years of age)

Date _______________ Time _______________

H.PYLORI TESTS

M HP £ H. Pylori Antigen (Stool)

OTHER TESTS NOT LISTED

Patient Service Centre Locations1. North Hill #254 North Hill Shopping Centre, 1632 – 14 Avenue NW Mon-Fri 7:00 am - 4:30pm

2. Market Mall Professional Centre 300, 4935 – 40 Avenue NW Mon-Fri 6:30 am - 6:00pm, Sat/Sun 7:00am - 3:00pm

3. Cochrane Communith Health Centre 60 Grande Blvd., Cochrane, AB Mon-Fri 7:00 am - 4:30pm

4. Ranchlands 150 – 1829 Ranchlands Blvd., NW Mon-Fri 6:30 am - 4:00pm Sat/Holidays 7:00 am - 3:00pm Appointment Only

5. Beddington Town Centre 209 – 8120 Beddington Blvd, NW Mon-Fri 6:30 am - 6:00pm, Sat 7:00am - 3:00pm

6. Airdrie Patient Service Centre 103 – 217 Centre Avenue SW, Airdrie, AB Mon-Fri 7:00 am - 4:30pm

7. McKnight Village 5426 Falsbridge Drive NE Mon-Fri 6:30 am - 4:00pm, Sat 7:00am - 3:00pm

8. Sunridge 3, 2681 – 36 Street NE Mon-Fri 6:30 am - 6:00pm, Sat/Sun 7:00am - 3:00pm

9. Chestermere Health Centre Appointment Only 288 Kinniburgh Blvd., Chestermere, AB Mon-Fri 8:30 am - 12:00pm

10. Marlborough #455 Marlborough Mall Prof. Tower, 433 Marlborough Way NE Mon-Fri 6:30 am - 4:00pm, Sat 7:00am - 3:00pm

11. Gulf Canada Square 344, 401 – 9th Avenue SW Mon-Fri 7:00 am - 4:30pm

12. Sheldon Chumir Health Centre 1213 – 4th Street SW Mon-Fri 7:00 am - 4:30pm

13. Glenbrook Plaza 154, 3715 – 51 Street SW Mon-Fri 6:30 am - 6:00pm, Sat 7:00am - 3:00pm

14. Sloane Square 210, 5920 – 1A Street SW Mon-Fri 7:00 am - 4:30pm, Sat 7:00am - 3:00pm

15. Glenmore Landing D264, 1600 – 90 Avenue SW Mon-Fri 7:00 am - 4:30pm

16. Riverbend 180 – 200 Rivercrest Drive SE (Riverbend Atrium) Mon-Fri 7:00 am - 4:30pm

17. Avenida Village Bay 517 – 12445 Lake Fraser Drive SE Mon-Fri 6:30 am - 4:00pm

18. South Calgary Health Centre 211 – 31 Sunpark Plaza SE, South Entrance Mon-Fri 6:30 am - 6:00pm, Sat/Sun/Holidays 7:00am - 3:00pm

18

17

1615

14

13

1211

110

98

2

4

3

7

6

5

Biotin: Biotin oral supplements may interfere with lab tests. CLS recommends all patients discontinue Biotin supplements for 48 hours prior to specimen collection. If your Health Care Provider recommended you take Biotin, contact them for further guidance.For Pregnant patients: The glucose drink is not given if the fasting glucose is high enough to suggest gestational diabetes mellitus (GDM). Write “Give glucose drink regardless of fasting glucose’ on the requisition if you wish to override this procedure, e.g. mother at high-risk of GDM and patient early in pregnancy (<20 weeks gestation).Lipid�Profile:�Fasting not required by the lab. For more information, please contact your physician or visit Http://www.topalbertadoctors.org/cpgs/

For all Patient information and inquiries, visit the CLS website: www.calgarylabservices.comPhysicians requiring test results, contact the CLS Laboratory Information Centre

Community Stat Tests: Only the following tests are available with results reported within 8 hours of collection.A stat test should only be requested in an emergency medical circumstance.

Alanine Aminotransferase (ALT)Beta HCG (Qualitative Urine)Beta HCG (Quantitative Serum)Bilirubin, Direct, Neonatal, Total CalciumCBCChloride

CreatinineGlucoseLipaseMagnesiumPotassiumPseudocholinesterase

Prothrombin Time/INRPTTSodiumUrinalysis

DRUG LEVELSAcetaminophenDigoxinPhenytoinLithiumSalicylateValproate