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