Test Request Forms / Requisitions

General Laboratory

Community Requisition (REQ9012PSC) *†Δ 

Acute Care Requisition (REQ9011RRL) †Δ 

Mobile Services Collection Requisition (REQ9013MOB)

Microbiology

Microbiology Requisition (REQ9021MI) *†Δ 

Microbiology Infection Surveillance Requisition (7828M) †Δ 

Malaria History Form (MI6002) *

Anatomic Pathology

Anatomic Pathology Community Requisition (REQ9031AP) *†Δ  Sample

Anatomic Pathology Acute Care Requisition (REQ9032AP) *†Δ  Sample

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

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

Request for Placenta Histopathology (REQ9036AP) †Δ Sample  

Molecular Pathology Requisition (REQ9038AP)

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

Oncology Consult / Test Request (AP1006C)

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 (CY1105)

Transfusion Medicine

Pretransfusion Testing Requisition (REQ9004TM) †Δ  Sample

ACH Blood Order Product Fax Requisition (REQ9002TM) Sample - Internal use only

Blood Product Product Fax Requisition (REQ9006TM) Internal use only

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

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

Specialty Requisitions

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

Bone Marrow Pathology Requisition (REQ9061BM) Sample - Contact FMC Special Hematology at 403-944-8070 for requisitions

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

Flow Cytometry Requisition (FC3200) Δ 

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

Rapid HIV Test Requisition (CH3062) Δ  Clinical restrictions apply

Request for Intra-Operative Pathology Consultation Requisition (100884) Δ 

Tissue Typing Requisition (REQ9054TT) Δ 

Urine Chain of Custody Requisition (DS3605) Sample - Internal use only

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.

How to Order Requisitions

* Acute Care and Community Physicians (within Calgary): Available for order using CLS form #PUR7507 or #PUR7503
http://www.calgarylabservices.com/files/CLSForms/PUR7507.pdf 
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 through the CHR legacy website http://iweb.calgaryhealthregion.ca/departments/supportservices/forms_printing_services/index.htm