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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 & General Laboratory

GL3456  Viral Haemorrhagic Fever Collection Kit Instructions for Use

PX4155 Special Arrangement for Neonatal Bilirubin Collection - Instructions for Parents

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Drug Screens

PX4162  Drug Screen Comprehensive Drug Analysis Medical History 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

MI6009  Urine Vacutainer Tube for Culture and Sensitivity

MI6011 Stool Ova & Parasite History Form

MI6044 Instructions for Use of Attests-Biological Indicators

MI6106  Gastric or Duodenal Biopsy Collection for Helicobacter Collection  

MI6115  Malarial Smear Preparation

MI6169 Labels - South Zone Microbiology Problem Bench

MI6170 APTIMA Vaginal Swab Specimen Collection Kit for Chlamydia trachomatis/Neisseria gonorrhoeae/Trichomonas vaginalis testing in Females

MI6173 Catheter Collection for Urine Culture 

Microbiology Specimen Collection Containers: Click Here

Physician Information Forms

CSD2703  Delivery of Hard Copy Reports During a Health Care Provider Absence

CSD2708  Healthcare Provider Information Form

CSD2709  Healthcare Provider Practice/Location Closure

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

SC4915  Heparin Induced Thrombocytopenia Antibody (HITABS) History Form

Transfusion Medicine

TM1555  Sites External to Urban CLS TM Supply Request

TM1623  Instructions for Patient Pick Up of Rh Immune Globulin

TM1723  Preoperative Pretransfusion Testing TM Supplies Request

TM1795 South Zone Order for Modified Blood Components from FMC

TM1844  Midwife Program TM Newborn Cord Specimen Label Request

TM1922  Public Health Request for Transfusion Summary

TM2012 Disposition of Blood Products Transported with a Patient

TM2038  Immune Globulin Initiation Form

TM2027  Identification Band for Pretransfusion Testing

TM2034  Adverse Reactions to Blood Products Notification

TM2111  Crossmatched Blood Available in Satellite Blood Storage Refrigerator

TM2145  Recycling Product (External Sites Packaging Slips)

TM2153  Request for DAT on Cord Blood

TM2089  Specimen Referral

TM2191  Physician Request for Transfusion Summary 

TM2151  External Sites - Segment Testing