Laboratory Use Only

Ministry of Health
and Long-Term Care
Laboratory Requisition
Requisitioning Clinician / Practitioner
Name

Address

Clinician/Practitioner’s Contact Number for Urgent Results Service Date

yyyy mm dd
( )
Clinician/Practitioner Number CPSO / Registration No. Health Number Version Sex Date of Birth
yyyy mm dd
M F
Check () one: Province Other Provincial Registration Number Patient’s Telephone Contact Number
OHIP/Insured Third Party / Uninsured WSIB ( )
Additional Clinical Information (e.g. diagnosis) Patient’s Last Name (as per OHIP Card)

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

Copy to: Clinician/Practitioner Patient’s Address (including Postal Code)

Last Name First Name

Address

Note: Separate requisitions are required for cytology, histology / pathology, ColonCancerCheck FIT test, and tests performed by Public Health Laboratory
x Biochemistry x Hematology x Viral Hepatitis (check one only)
Glucose Random Fasting CBC Acute Hepatitis
HbA1C Prothrombin Time (INR) Chronic Hepatitis
Creatinine (eGFR) Immunology Immune Status / Previous Exposure
Specify: Hepatitis A
Uric Acid Pregnancy Test (Urine)
Hepatitis B
Sodium Mononucleosis Screen
Hepatitis C
Potassium Rubella
or order individual hepatitis tests in the
ALT “Other Tests” section below
Prenatal: ABO, RhD, Antibody Screen
Alk. Phosphatase (titre and ident. if positive) Prostate Specific Antigen (PSA)
Bilirubin Repeat Prenatal Antibodies Total PSA Free PSA
Albumin Microbiology ID & Sensitivities Specify one below:
(if warranted) Insured – Meets OHIP eligibility criteria
Lipid Assessment (includes Cholesterol, HDL-C, Triglycerides,
calculated LDL-C & Chol/HDL-C ratio; individual lipid tests may Cervical Uninsured – Screening: Patient responsible for payment
be ordered in the “Other Tests” section of this form)
Vaginal Vitamin D (25-Hydroxy)
Albumin / Creatinine Ratio, Urine Vaginal / Rectal – Group B Strep Insured - Meets OHIP eligibility criteria:
Urinalysis (Chemical) Chlamydia (specify source): osteopenia; osteoporosis; rickets;
renal disease; malabsorption syndromes;
Neonatal Bilirubin: GC (specify source): medications affecting vitamin D metabolism
Child’s Age: days hours Sputum Uninsured - Patient responsible for payment

Clinician/Practitioner’s tel. no. ( ) Throat Other Tests - one test per line
Patient’s 24 hr telephone no. ( ) Wound (specify source):
Therapeutic Drug Monitoring: Urine
Name of Drug #1 Stool Culture
Name of Drug #2 Stool Ova & Parasites
Time Collected #1 hr. #2 hr. Other Swabs / Pus (specify source):
Time of Last Dose #1 hr. #2 hr.
Time of Next Dose #1 hr. #2 hr.

I hereby certify the tests ordered are not for registered in or

out patients of a hospital. Specimen Collection
Time Date
24 hour clock yyyy/mm/dd

Laboratory Use Only

X
Clinician/Practitioner Signature Date

4422-84 (2019/05) © Queen’s Printer for Ontario, 2019 7530-4581

 Date received PHOL No.

yyyy / mm / dd

General Test Requisition

ALL Sections of this Form MUST be Completed
1 - Submitter 2 - Patient Information
Courier Code Health No. Sex Date of Birth:
yyyy / mm / dd
Medical Record No.
Provide Return Address:
Patient’s Last Name (per OHIP card) First Name (per OHIP card)
Name
Address
City & Province
Patient Address
Postal Code

Postal Code Patient Phone No.

Clinician Initial / Surname and OHIP / CPSO Number

Submitter Lab No.

Tel:
T Fax:
Public Health Unit Outbreak No.

cc Doctor Information Public Health Investigator Information

Name: Tel: Name:
Lab/Clinic Name: Fax: Health Unit:
CPSO #:
Address: Postal Code: Tel: Fax:

3 - Test(s) Requested (Please see descriptions on reverse) Hepatitis Serology

Test: Enter test descriptions below

Reason for test (Check ( ) only one box):

Immune status
Acute infection
Chronic infection
Indicate specific viruses (Check ( ) all that apply):

Hepatitis A
Hepatitis B
Hepatitis C (testing only available for acute or chronic infection; no test for
determining immunity to HCV is currently available)

4 - Specimen Type and Site Patient Setting

blood / serum faeces nasopharyngeal physician office/clinic ER (not admitted)

sputum urine vaginal smear inpatient (ward) inpatient (ICU) institution
urethral cervix BAL
other - (specify)

5 - Reason for Test

Clinical Information
diagnostic immune status Date Collected:
fever gastroenteritis respiratory symptoms
needle stick follow-up yyyy / mm / dd STI headache / stiff neck vesicular rash
prenatal chronic condition pregnant encephalitis / meningitis maculopapular rash
Onset Date:
immunocompromised jaundice
yyyy / mm / dd
post-mortem other - (specify)
other - (specify)
influenza high risk - (specify)
recent travel - (specify location)

For HIV, please use the HIV serology form. - For referred cultures, please use the reference bacteriology form.To re-order this test requisition contact your local Public Health
Laboratory and ask for form number F-SD-SCG-1000. Current version of Public Health Laboratory requisitions are available at www.publichealthontario.ca/requisitions
The personal health information is collected under the authority of the Personal Health Information Protection Act, s.36 (1)(c)(iii) for the purpose of clinical laboratory testing. If you have questions
about the collection of this personal health information please contact the PHOL Manager of Customer Service at 416-235-6556 or toll free 1-877-604-4567. F-SD-SCG-1000 (08/2013)