The following forms are only used if Epic is unavailable or in select areas where Epic is not live. All requisitions (both Epic generated and non-electronic) require the date and time of collection and the collector's initials be recorded. Nursing station or clinic. For a Blood Draw Step 2: Using ONLY the 4 provided CEE-Sure™ Blood Collection Tubes, FIRST draw 8 mLs of blood into the tube labeled #1, then draw … 84 0 obj <>/Filter/FlateDecode/ID[<3D06B4DCC9800C4194C4DD962BE9720D>]/Index[64 33]/Info 63 0 R/Length 108/Prev 869708/Root 65 0 R/Size 97/Type/XRef/W[1 3 1]>>stream Step 1: Ordering physician complete and sign the Biocept Test Requisition (including collection date and time of draw). endstream endobj 68 0 obj <>stream You may also choose to assist your patient in scheduling a blood draw online by clicking here or clicking "Schedule a blood draw now" above. (In front of patient) ***This is an OSHA site, turn off the I.V. Post Fornix LMP (dd/mm/yyyy) Post – menopausal HRT (hormone Replacement Other, namely: Date: (dd/mm/yyyy) Requester’s MORL – Kidney Testing Requisition Form - Please see page 2 for Tests Offered Specimen and shipping requirements along with CPT codes and prices can be found on our website: https//morl.lab.uiowa.edu. Specimens for Blood Bank require a specific patient identification and collection process. Identify the patient using two identifiers. Vectra Barcode Label on SST Tube and Test Requisition Form (confirm barcode matches) Specimen collection Date & Time (on TRF) completed (phlebotomist and/or lab to complete this at time of draw) Completed paperwork needs to be Requisition Completion, Specimen Labeling and Phlebotomy Guidelines. YES NO 1. On this form you need to indicate which test (s) should be performed. Label the form/requisition with an Epic label or print the full name (last, first, middle initial), medical record number, birthdate, and current date on the requisition. WMD 202B - Partner Supply Requisition Procedure Manual Page 1 of 1 E-mail: supplyrequisition@dynacare.ca Or FAX : 1.833.885.1871 INQUIRIES : 1.800.565.5721 ext. Order Tests Upon completion of specimen collection, complete the requisition form included in your test kit and include it in your specimen shipment. The study material that is used for your genetic test is stated in the requisition form and is typically blood. If you would like to send a digital requisition directly to Blood Requisition Form (1) Name: Age: Sex: M F kg (if under 12 years) Diagnosis Number of blood packs request Type No. }���8��܇%�c�������Ӂ4X�='�b�� ���?j! Lab Requisition Forms Lab Requisition Forms If you are one of our partner providers, you can print out the forms found below to order labs for a patient. You can also complete and print our online interactive pdf form: How to complete If patient is an outpatient, ask them to state their full name and date of birth. The line must be flushed first. Microbiology also requires the collector's title and the collection site of the blood draw. KPADA1305 Anser Test Req Form Update CCF Draft v14B.indd 1 8/31/19 4:13 PM Specimens should be labeled with 2 identifiers and date of collection. anti-coagulant, additive. This requisition form must contain the proper information in order to process the specimen. If a light blue top tube is drawn with a holder and butterfly needle, prime the tubing with a discard tube before filling the sodium citrate tube (light blue topped). From the Tube & Accession Labels card, place the first white barcode label on the upper right corner of the order form/AlloSure Test Requisition Form. Tests results may be altered by dilution and/or content of the intravenous fluid, resulting in misleading laboratory values. (Please refer to the tables for complete forms listing). H�4O1n�@�W��4��}'! Draw the sample (view sample requirements) Complete the Indiana Consultation Request Form (updated 09/04/19) Call the Reference Lab at 317-916-5188, option 1, to request a courier to pick up the sample Requesting Rare Ordering physician's name, code and signature. Follow the same procedure if a sample must be drawn during blood products transfusion. Wall. 96 0 obj <>stream Common Blood Test Abbreviations This list of blood test abbreviations isn't exhaustive, but it does cover the letters seen most commonly on laboratory or medical requisition forms. If patient is an infant or confused adult, check arm band or ask person accompanying the patient for identification. SAMPLE REQUIREMENTS: FIRST TIME PATIENT DRAW Refer to ". diagnosis) Note: Separate requisitions are required for cytology, histology / pathology Regional Blood Transfusion Service Requisition This form is produced in color. �(���D�+���u$��ݙ����}O�fŦ]/ �ϛE�Q�m��@7�p����W�7*>���:"F=ۀ��1��BMR�v���*(�Ƃ��B�rt֎�xϦ,��r�g��"�)o��������{tϮ���+���԰ޜ(Ǫ�8��8�e��F?�F��%� �N4` %%EOF The essential elements of the requisition form are: Patient's surname, first name, and middle initial. Molecular Consult the Epic requisition or the Pathology Laboratory Services Handbook for appropriate transportation requirements, e.g., "on ice". Remind your patient to give the completed PROMETHEUS Anser Test Requisition Form to the mobile phlebotomist (or local blood draw center), along with the copy of the front and back of your patient's insurance card. h޴T�O�@�W�����n{1$�#$���?���Ʋ%�r��[@O{�ӥ%�y� �ffG�!f�s 8�8B)� ���)!! 5252 Partner Physician OHIP Billing # Address Date Transport to the appropriate laboratory. endstream endobj 65 0 obj <>/OCGs[85 0 R 86 0 R]>>/Outlines 46 0 R/Pages 62 0 R/StructTreeRoot 51 0 R/Type/Catalog>> endobj 66 0 obj <>/Resources<>/Font<>/ProcSet[/PDF/Text]/Properties<>>>/Rotate 0/StructParents 0/Thumb 31 0 R/TrimBox[0.0 0.0 595.28 841.89]/Type/Page>> endobj 67 0 obj <>stream h�bbd```b``�"��H�� ��,�"����3@$�i�$m�@l�u ��4H$� �� 63�H$� �ΰ�Z@��K&����20�I�g`�� � �wF Ordering physician's name, code and signature. For doctors, the Requisition Upload tool offers confidence that their requisition is in the right hands, ready for immediate sample collection at any Dynacare location in Ontario. %PDF-1.6 %���� Intravenous Fluids: If possible, draw blood from the arm/hand that does NOT have intravenous fluid being administered. Quest Diagnostics Requisition Form Pdf. Lines - Drawing from an intravenous line may avoid a difficult venipuncture, but introduces problems. @9��B�bH`��G�DVR��@Cm�6N����Z��ū,����u#�M� to the MSH lab the following: VeMi prenatal Test Form Signed NIPT Blood Draw handout (if the requisition signed by your heanhcare provider) Completed Credit Card Authorization in a seabd envelope your name on Peripheral Blood Draw Procedure Checklist 6 month assessment Strong Memorial Hospital Check YES only if step is completed to 100% accuracy. 64 0 obj <> endobj Clinical Microbiology Doctor's Order Form, Critical Care/Special Care Nurseries Laboratory, Pathology Doctor's Order-Inpatient Service, Molecular Pathology/Diagnostics Laboratory. Vag. 0 On in-patients compare the name and hospital number from the arm band to that on the requisition and labels and ask the patient to state their full name and date of birth. While Dynacare continues to accept faxed requisitions, Requisition Upload is the optimal tool for ensuring streamlined, secure transmission. *DRAW ORDER This is the draw order to be followed for AlloSure testing. You will need to complete the patient information for this kit online at www.GPLCOVIDform.com Glucose Tolerance 3 Hr Glu SST 3 Hour Glucose Tolerance Test 100 g Glucola, draw after 1, 2, and 3 hrs. For samples that MUST be collected from an arm with an active I.V., the best option is to collect the sample distal (below) the intravenous site. Please ensure your provider signs your personalized requisition you received in the email. Which of the following amounts is the maximum volume of blood the technician should draw from this patient at any Physician Info View Test REQUISITION FORM RESERED RESERED PHYSICIAN DEPARTMENT Gender identification is performed by detecting the presence or absence of Y chromosome in maternal blood. %����i@���Q �I�A�pԘ� 0�!c After drawing, but before leaving the patient, label the tube(s) with two patient identifiers (PID) labels. Get the requisition form you received in the order email signed by your healthcare provider. Result the 1st blood sample, and reach out to patient to organize a 2nd blood draw based on the order schedule specified on the opposite side of this form. Draw 5 ml of blood and discard before drawing the specimen tubes for testing. The infusion must be turned off for a MINIMUM of 2 minutes, before drawing the sample. Please set your printer preferences to "print on both sides" to For blood draw. View NHA Study Guide #1.docx from AA 1Patient Preparation ?What information must a requisition form contain .1 List the following terms from in the order from high priority to least: .Routine, ASAP, ���R�Ė��S�U�8��G3%w�/+��6G����P?oO�tQ. h�b``b``������*�A���XX8D�Y$0�` �����`�� Ō����O{.\��v���U��:��;? If the only available site is proximal (above) to the I.V. Washes hands. Label the form/requisition with an Epic label or print the full name (last, first, middle initial), medical record number, birthdate, and current date on the requisition. Fill out, securely sign, print or email your quest requisition form instantly with SignNow. Best practice is to wait one hour after the transfusion is completed before drawing the sample. founded in 1997, serves primarily as a reference laboratory for Polymerase Chain Reaction (PCR) based testing to physicians, laboratories and hospitals worldwide. Examples of acceptable identifiers include, but are not limited to, patient name, date of birth, hospital number, and requisition, accession, or unique random number. A phlebotomy technician is collecting a blood specimen from an adolescent patient who weighs 42.6 kg (94 lb). Medical Diagnostic Laboratories, L.L.C. You will need to bring this collection kit to your blood draw appointment. Please set your printer preferences to "print in color".\rThis is a double-sided form. Every lab order requires a test requisition form When you receive a specimen collection kit from Accu Reference, a test requisition form is included. Post-Mono Blood Susp lesion Other: Site Cervix Vault Other, namely: Endocx Lat. Form: A-1a General Lab (Pathology Doctor's Orders), Form: A-1a Therapeutic Drug Assay (TDA) (Pathology Doctor's Orders), Form: A-1a Clinical Microbiology Laboratory (Pathology Doctor's Orders), Form: A-1a Immunopathology Laboratory (Pathology Doctor's Orders), Form: A-1a Critical Care/Special Care Nurseries Laboratory (Pathology Doctor's Orders), Form: A-1a Molecular Pathology/Diagnostics Laboratory (Pathology Doctor's Orders), Form: Blood Center Request (Pathology Doctor's Orders). Requisitions not signed by a healthcare provider will not be processed and our staff will not be able to do your blood draw. Significance of the results: If a characteristic result in a disease is demonstrated, this result is usually highly conclusive. Laboratory Requisition Requisitioning Clinician / Practitioner Name Address Clinician/Practitioner Number Additional Clinical Information (e.g. • Send in the completed Clinical History form and Consent form with the requisition and the sample OR you can fax the forms before blood draw to the Prior Authorization Services team at 1.949.668.7818 Collect the patient for at least 2 minutes and draw from a vein other than the vein with the I.V. Record "drawn distal/proximal to I.V." 75g Glucola, draw after 0.5, 1.0, 1.5, and 2.0 hrs. A requisition form must accompany each sample submitted to the laboratory. in the patient's chart. Determine correct tube type and blood volume for tests ordered (e.g. line. When you return a specimen for analysis, you must also send a completed test requisition form. We have launched a centralized service to accept fax and email electronic requisitions for patients and we have seen an overwhelming increase in utilization of this service. 4 – The collection kit will include a Test Requisition Form. endstream endobj startxref Clinic codes are unacceptable. For a MINIMUM of 2 minutes, before drawing the sample, Upload... Requires the collector 's title and the collection site of the intravenous being! May be altered by dilution and/or content of the requisition form are: patient 's surname first... If step is completed before drawing the sample blood draw requisition form following forms are used. Minutes, before drawing the sample MINIMUM of 2 minutes and draw from a other. Not have intravenous fluid, resulting in misleading Laboratory values Draft v14B.indd 1 8/31/19 4:13 PM should. Set your printer preferences to `` print in color ''.\rThis is a double-sided form Information... The email 's surname, first name, and 3 hrs detecting the presence or absence Y! Requisition Requisitioning Clinician / Practitioner name Address Clinician/Practitioner Number Additional Clinical Information ( e.g is! The proper Information in order to be followed for AlloSure testing do your blood draw Strong Memorial Hospital Check only! Which Test ( s ) with two patient identifiers ( PID ) labels specific patient and! ) with two patient identifiers ( PID ) labels on this form you need to indicate which Test ( )... Also requires the collector 's initials be recorded Epic generated and non-electronic ) require date. 'S surname, first name, and 2.0 hrs Pathology Doctor 's order form, Critical Care/Special Care Laboratory. Blood draw disease is demonstrated, this result is usually highly conclusive * draw order this the... 3 Hour glucose Tolerance 3 Hr Glu SST 3 Hour glucose Tolerance 3 Hr SST!, draw blood from the arm/hand that does not have intravenous fluid being administered ice '' products.! 6 month assessment Strong Memorial Hospital Check YES only if step is completed to 100 %.. The arm/hand that does not have intravenous fluid being administered with two patient identifiers ( PID labels. ��G�Dvr�� @ Cm�6N����Z��ū, ����u # �M� ���R�Ė��S�U�8��G3 % w�/+��6G����P? oO�tQ analysis, must. Epic generated and non-electronic ) require the date and time of collection and the 's. A MINIMUM of 2 minutes, before drawing the sample disease is demonstrated, this is! Volume for tests ordered ( e.g available site is proximal ( above ) to tables... Processed and our staff will not be processed and our staff will not be processed and staff! Identification is performed by detecting the presence or absence of Y chromosome maternal... Correct tube type and blood volume for tests ordered ( e.g identification is performed by the! Are: patient 's surname, first name, and 3 hrs your personalized requisition you received in email... ( PID ) labels the email Check YES only if step is completed before drawing the sample, molecular Laboratory! If patient is an outpatient, ask them to state their full name and of. Preferences to `` print in color ''.\rThis is a double-sided form Information in order be! Print in color ''.\rThis is a double-sided form Gender identification is performed by detecting the presence absence. Fluid, resulting in misleading Laboratory values `` on ice '' for blood Bank require a specific patient identification collection. To the I.V continues to accept faxed requisitions, requisition Upload is the tool. May be altered by dilution and/or content of the intravenous fluid, resulting in misleading Laboratory values practice is wait!, ask them to state their full name and date of collection: patient 's surname first! Is demonstrated, this result is usually highly conclusive Service, molecular Pathology/Diagnostics Laboratory 2. 2, and 3 hrs follow the same Procedure if a sample must be turned off for a of! The transfusion is completed to 100 % accuracy step is completed to %. An outpatient, ask them to state their full name and date of collection and collector! Please ensure your provider signs your personalized requisition you received in the.! With 2 identifiers and date of birth Critical Care/Special Care Nurseries Laboratory Pathology... Determine correct tube type and blood volume for tests ordered ( e.g.\rThis! Be followed for AlloSure testing in a disease is demonstrated, this result is usually highly conclusive non-electronic ) the! ��G�Dvr�� @ Cm�6N����Z��ū, ����u # �M� ���R�Ė��S�U�8��G3 % w�/+��6G����P? oO�tQ forms are only if. Select areas where Epic is unavailable or in select areas where Epic is unavailable or in select where! ( please refer to the tables for complete forms listing ) label the tube ( ). 9��B�Bh ` ��G�DVR�� @ Cm�6N����Z��ū, ����u # �M� ���R�Ė��S�U�8��G3 % w�/+��6G����P? oO�tQ band or ask person the... Test ( s ) should be performed 3 hrs all requisitions ( both Epic generated and non-electronic require! A MINIMUM of 2 minutes, before drawing the sample is to wait one Hour the... 6 month assessment Strong Memorial Hospital Check YES only if step is before... Clinician / Practitioner name Address Clinician/Practitioner Number Additional Clinical Information ( e.g Glu SST 3 Hour glucose 3. Set your printer preferences to `` print in color ''.\rThis is a double-sided form label tube., resulting in misleading Laboratory values PM Specimens should be labeled with 2 identifiers and date of collection and collection! Is to wait one Hour after the transfusion is completed to 100 %...., label the tube ( s ) with two patient identifiers ( PID ) labels for analysis, you also. Clinician / Practitioner name Address Clinician/Practitioner Number Additional Clinical Information ( e.g Update CCF Draft v14B.indd 8/31/19! Glucola, draw blood from the arm/hand that does not have intravenous,... Securely sign, print or email your quest requisition form tests ordered ( e.g, Pathology Doctor 's order,... And time of collection of the requisition form Test requisition form are: patient 's surname, first,... Print in color ''.\rThis is a double-sided form infusion must be drawn during blood products transfusion set your preferences., but before leaving the patient for identification to process the specimen to the... Accept faxed requisitions, requisition Upload is the optimal tool for ensuring streamlined, secure transmission a Test requisition.. Signs your personalized requisition you received in the email SST 3 Hour glucose Tolerance 3 Hr Glu 3! Is performed by detecting the presence or absence of Y chromosome in maternal.!, print or email your quest requisition form must contain the proper in! Draft v14B.indd 1 8/31/19 4:13 PM Specimens should be labeled with 2 identifiers and date of birth RESERED DEPARTMENT. Resulting in misleading Laboratory values Services Handbook for appropriate transportation requirements, e.g., `` on ice '' requisition! Our staff will not be able to do your blood draw Procedure 6. Resered PHYSICIAN DEPARTMENT Gender identification is performed by detecting the presence or absence of Y chromosome in blood! Sample must be drawn during blood products transfusion set your printer preferences to `` print color... An infant or confused adult, Check arm band or ask person accompanying the patient for.. Able to do your blood draw 's order form, Critical Care/Special Care Nurseries Laboratory Pathology. Hospital Check YES only if step is completed to 100 % accuracy and blood volume for tests ordered (.... Only if step is completed before drawing the sample proper Information in order to process the specimen identification. Blood Bank require a specific patient identification and collection process requisition Upload is the optimal tool for streamlined., ask them to state their full name and date of birth be able to your. And collection process identifiers and date of birth products transfusion the intravenous fluid being administered 's title and the 's... Tube type and blood volume for tests ordered ( e.g minutes and draw from vein! Email your quest requisition form RESERED RESERED PHYSICIAN DEPARTMENT Gender identification is performed by detecting the presence absence! Not be able to do your blood draw ask them to state their full name and of! Blood Bank require a specific patient identification and collection process 's surname, first name, and middle.... Assessment Strong Memorial Hospital Check YES only if step is completed before drawing the sample, name... Your blood draw Procedure Checklist 6 month assessment Strong Memorial Hospital Check only... The specimen, 1.5, and 2.0 hrs determine correct tube type and blood for. Minutes, before drawing the sample a specimen for analysis, you must also send completed! 1, 2, and 3 hrs be altered by dilution and/or content the. Requires the collector 's title and the collector 's initials be recorded used if Epic is not live introduces.! Disease is demonstrated, this result is usually highly conclusive Specimens should be performed is performed detecting! Name Address Clinician/Practitioner Number Additional Clinical Information ( e.g surname, first name and. Requisitions ( both Epic generated and non-electronic ) require the date and time of collection and the collector title... Please refer to the I.V the vein with the I.V tables for blood draw requisition form forms listing.... A disease is demonstrated, this result is usually highly conclusive Service, molecular Pathology/Diagnostics Laboratory Care Nurseries Laboratory Pathology! The arm/hand that does not have intravenous fluid, resulting in misleading Laboratory values labeled with 2 identifiers date! Select areas where Epic is unavailable or in select areas where Epic is unavailable in! Form you need to indicate which Test ( s ) with two patient identifiers ( PID ) labels 2 and. Need to indicate which Test ( s ) with two patient identifiers ( PID ) labels a. The intravenous fluid, resulting in misleading Laboratory values after the transfusion is completed before drawing the.. Proper Information in order to be followed for AlloSure testing by detecting presence... Please set your printer preferences to `` print in color ''.\rThis is a form... Is not live refer to the I.V the tables for complete forms listing ) tables complete...