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Test Request Forms / Requisitions

General Laboratory

General Laboratory Requisition - 21302 (Community Requisition REQ9012PSC has been replaced by General Laboratory Requisition 21302) *Δ 

Electrocardiogram Requisition (REQ9015ECG) *Δ 

Acute Care Requisition (REQ9011RRL) Δ 

(Calgary Rural Laboratory Requisition REQ9014RURAL has been replace by General Laboratory Requisition 21302) Δ

Mobile Collection Service Requisition (REQ9013MOB)

Microbiology

Microbiology Requisition (REQ9021MI) *Δ 

Microbiology Infection Surveillance Requisition (7828M) Δ 

Malaria History Form (MI6002) *

Stool Ova & Parasite History Form  (MI6011)

Microbiology Specimen Referral Requisition  (MI6089)

Microbiology Reference Organism & Specimen Investigation Request (MI6123)

Anatomic Pathology

AHS Anatomical Pathology Requisition (Consultation Request) 19027

Immunohistochemistry Request Form (AP1057)

Ophthalmic Pathology Consultation Requisition (REQ9033AP) For use by Ophthalmic Surgical Clinic only

Intra-Operative Neuropathology Consultation Requisition (REQ9034AP) Δ For use by OR staff only

Dermatopathology Consult Test Request Form (REQ9035AP) *

Request for Placenta Histopathology (REQ9036AP) †Δ 

Molecular Pathology Requisition (REQ9038AP)

Request for Intra-Operative Pathology Consultation (REQ9039AP) For use by OR staff only. 

Oncology Consult / Test Request (APCY1006C)

Cytopathology

Gynecological Cytopathology Requisition (REQ9043CY-GYN) *Δ 

Non-Gynecological Cytopathology Requisition (REQ9041CY-NON) *Δ 

Colposcopy Pathology Requisition/Worksheet (REQ9042COL) *†Δ 

Fine Needle Aspiration (FNA) Clinic Patient Referral Form (REQ9044FNA)

Transfusion Medicine

Adverse Reactions to Blood Products Notification (TM2034)

AHS Hemophilia Factor Concentrates Order Form (101120)

Blood Component/Product Requisition - Adult (REQ9006TM)

Blood Component/Product Requisition - Neonatal/Pediatric (REQ9002TM)

Blood Component/Product Requisition - Rural (REQ9010TM)

Dispense of Blood Components/Products  (TM1763)

Genotyping for Red Cell Antigens Requisition (REQ9007TM)

Immune Globulin Initiation Form  (TM2038)

Notification to Transfusion Medicine of ABO Incompatible Transplant (TM1892)

Post Natal Requisition (REQ9009TM)

Preliminary Laboratory Testing for Directed Blood Donation - Intended Donor (REQ9005TM)

Preliminary Laboratory Testing for Directed Blood Donation - Intended Recipient (REQ9003TM) 

Pretransfusion Testing Requisition (REQ9004TM) Δ 

Subcutaneous Immune Globulin Product Order and Home use Dispense Requisition (REQ9008TM)

Specialty Requisitions

Adrenal Venous Sampling Requisition (REQ9067AVS) For use by Diagnostic Imaging only

AHS Maternal Prenatal Screen Requisition (CH-1247) for Second Trimester Quad Screen ONLY

First Trimester Combined Screen (FTS) Requisition (REQ9080) - for First Trimester screening

Bronchoalveolar Lavage/ Bronchial Wash Requisition REQ9024MI

Bone Marrow Pathology Requisition (REQ9061BM)

Chromosome & FISH Studies - Cancer Cytogenetics (REQ9037AP) Sample - Contact Laboratory at 403-770-3690 for requisitions

Flow Cytometry Requisition (FC3200) Δ


Histocompatibility and Immunogenetics (HIL)/Tissue Typing Requisition (REQ9054TT-SO) Δ (Effective September 25, 2017)
Histocompatibility and Immunogenetics (HIL)/Tissue Typing Requisition (REQ9054TT-DA) Δ  (Effective September 25, 2017)
Histocompatibility and Immunogenetics (HIL)/Tissue Typing Requisition (REQ9054TT-HP) Δ  (Effective September 25, 2017)

Molecular Hematology Laboratory Requisition (REQ9053MH) Sample - Contact Laboratory at 403-770-3699 for requisitions

PADIS Medical Toxicology Clinic Requisition (REQ9016PADIS) For use at the PADIS Clinic only

HIV Serology by Rapid Assay (REQ9016HIV) Δ  Clinical restrictions apply

Vitamin D (25-Hydroxy) Requisition (19500) * Δ

Limited Services Requisition (REQ9051LTD) Only for use during a pandemic/disaster. CLS will communicate when this requisition should be used when approved by CLS Executive.

Urea Breath Test for Helicobacter Pylori (REQ9080UBT) Δ  Clinical restrictions apply

How to Order Requisitions

* Acute Care and Community Physicians (within Calgary): Available for order using CLS form #PUR7503
http://www.calgarylabservices.com/files/CLSForms/PUR7503.pdf

† Extra Regional Physicians (outside of Calgary): Available for order using CLS form #PUR7508 http://www.calgarylabservices.com/files/CLSForms/PUR7508.pdf

Δ AHS staff only: Available for order online from Data Printing Services: https://secure7.datagroup.ca.