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