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Test Request Forms / Requisitions

General Laboratory

Community Requisition (REQ9012PSC) *Δ 

Electrocardiogram Requisition (REQ9015ECG) *Δ 

Acute Care Requisition (REQ9011RRL) Δ 

Calgary Rural Laboratory Requisition (REQ9014RURAL) Δ

Mobile Services Collection 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)

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

Dermatopathology Consult Test Request Forn (REQ9035AP) *

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 (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)

Dispense of Blood Components/Products  (TM1763)

Genotyping for Red Cell Antigens Requisition (REQ9007TM)


IVIG History 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

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

Histocompatibility and Immunogenetics (HIL)/Tissue Typing Requisition (REQ9054TT) Δ 

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

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

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.

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.