REQUIRED INFORMATION

NON-GYNECOLOGICALCYTOPATHOLOGY REQUISITION

PROVINCE PERSONAL HEALTH NUMBER (PHN)

___ __ ___ ___ ___ --- ___ ___ ___ ___ REGIONAL HEALTH RECORD NUMBER

PATIENT LAST NAME FULL FIRST NAME MIDDLE NAME

PHYSICIAN TO ACT ON RESULTS:

Physician Last Name / Full First Name:

5 Digit Client #:

Alpha Suffix Provider #:

CHART NUMBER GENDER DATE OF BIRTH

__ __ __ __ / __ __ / __ __ Y Y Y Y M M D D

PATIENT PHONE NUMBER

( __ __ __ ) __ __ __ - __ __ __ __

PROCEDURE PERFORMED BY: SAME NAME / LOCATION AS ABOVE

______________________ _______________________ _____________________ Last Name Full First Name Location

CURRENT SPECIMEN TAKEN:

Date: __ __ __ __ / __ __ / __ __ Y Y Y Y M M D D

Time: __ __ : __ __ H H M M ADDITIONAL COPIES TO:

1) ______________________ _______________________ ____________________ Last Name Full First Name Location

2) ______________________ _______________________ ____________________ Last Name Full First Name Location

FOR LAB USE ONLY - ACCESSION NUMBER

Laboratory Information Centre: 403-770-3600 � 1-800-661-3450 www.calgarylabservices.com

SPECIMEN COLLECTION METHOD

BAL Brush Fluid FNA Scrape Wash

NON-GYNECOLOGICAL SPECIMEN SITE (You must complete a separate requisition for each specimen)

Ascites:___________________________________

Breast: ___________________________________

Bronchus: _________________________________

Common Bile Duct: _________________________

CSF: lumbar puncture shunt

Liver:____________________________________

Lung: ___________________________________

Lymph node:______________________________

Neck:____________________________________

Pancreas:_________________________________

Pelvis:_________________________________

Pericardium:_____________________________

Pleura: ________________________________

Retroperitoneum: ________________________

Salivary Gland : _________________________

Soft Tissue:_____________________________

Sputum:________________________________

Thyroid:________________________________

Urine:_________ Voided Catheterized

Other:__________________________________

CLINICAL INFORMATION (Please print clearly)

FOR LAB USE ONLY – Prep notes FOR LAB USE ONLY – Screener FOR LAB USE ONLY – Pathologist

®

Advanced Malignancy

Biomarker:

_______________________

_______________________

_______________________

Molecular:_______________________

_______________________

_______________________

(keep samples together)

PATIENT ADDRESS CITY, PROVINCE POSTAL CODE

•REQ9041CY-NON 2018/04/19

PROCESSING