Forms Related to Collection & Testing for Medical Professionals

Guidelines for healthcare professionals are subject to change. To ensure quality samples, please use the most current forms which are available below.

Chemistry

CH3011  Maternal Serum Prenatal Screen

Drug Screens

DS3601  Medical Drug Screen History Form for Community

Fine Needle Aspiration Clinic

CY1105  Fine Needle Aspiration (FNA) Clinic Patient Referral Form

Microbiology

MI6002  Malaria History Form

MI6004  Collection of Superficial Mycology Specimen - Guidelines for Physicians

MI6005  Collection of Samples for Anaerobes - Guideline for Physicians

MI6006  Critical Eye Specimen Instructions - Guideline for Physicians

MI6015  Herpes DFA Slide Sample Collection - Guidelines for Physicians

MI6106  Gastric or Duodenal Biopsy Collection for Helicobacter Collection  

MI6115  Malarial Smear Preparation

Molecular Hematology

MH4501 Heparin Induced Thrombocytopenia Antibody (HITABS) History Form

Physician Information Forms

CSD2703 Report Distribution During a Physician's Absence Form

CSD2708 Healthcare Provider Information Form

Special Coagulation

SC4900 Hemostasis Studies History Form

SC4901 Lupus Type Inhibitor History Form

SC4902 Thrombophilia Screen/Related Procedures History Form

SC4904 Factor Xa History Form

Transfusion Medicine

TM1623 Instructions for Patient Pick Up of Rh Immune Globulin

TM1641 Rh Prophylaxis for Cellular Therapy Patients

TM2038 Intravenous Immune Globulin (IVIG) History Form

TM2027 Identification Band for Pretransfusion Testing

TM2034 Adverse Reactions to Blood Products Notification

TM2153 Cord Blood DAT Request Fax

TM2191 Physician Request for Transfusion Summary 

TM2150 NiaStase - Notification to Physicians Considering Unlicensed Use

TM2157 Intravenous Immune Globulin (IVIG) Administration Information

TM1555 Sites External to CLS Supply Request List Fax Form

TM2145 Recycling Product (External Sites Packaging Slips)

TM1723 Hip & Knee Clinic TM Supplies Fax Request Form

Special Arrangements for Specimen Collection

OS7703  Special Arrangement for Neonatal Collection at CLS Hospital Outpatient Labs