TEST REQUISITION URINE & MISC BIOCHEMISTRY DEPARTMENT As per DSM Specimen Acceptance Policy 10-50-03 - Requirements for Test Requisitions 2.1 - All information marked with an asterisk* is mandatory and must be clearly legible. Failure to comply may result in specimen rejection. ORDERING PROVIDER INFORMATION PATIENT INFORMATION *Last & Full First Name: Billing Code: *Last/First Name: (As per Manitoba Health Card) *Ordering Facility and address: Inpatient Location: *Date of Birth: (dd/mmm/yyyy): *Critical Results Phone No: *Fax No: *SEX q Female q Male *MB PHIN: ADDITIONAL REPORT RECIPIENT PROVIDER INFORMATION - #1 *Alternate ID: (include ID type *Last & Full First Name: Billing Code: with number ie: RCMP, SK, DND, etc) *Ordering Facility and address: MRN: Encounter Number: *Phone No: *Fax No: *Patient Phone No: Demographics verified with: qProvincial Health Card qArmband qeChart/CR ADDITIONAL REPORT RECIPIENT PROVIDER INFORMATION - #2 COLLECTION INFORMATION *Last & Full First Name: Billing Code: *Collector: *Collector D/T: (dd/mmm/yyyy) *Ordering Facility and address: Circle for copy of report YES *Collector Facility: Collected Via: q Venipuncture q Capillary q Indwelling Line q Above Shut Off IV *Phone No: *Fax No: Referring Lab: Number of tubes sent: _____ Circle if samples shipped frozen EDTA _____ SST(gel) _____ Serum (no gel) _____ Citrate _____ Urine _____ AVAILABLE STAT AVAILABLE STAT ONLY AFTER PHYSICIAN HAS CONSULTED THE BIOCHEMIST ON CALL URINALYSIS AMNIOTIC FLUID URINE COMPLETE SCREEN UR LUNG PROFILE (FETAL LUNG MATURITY) LP COPPER (Random or 24h) COPU (SPECIAL COLLECTION) INCLUDES: INSULIN AMN FLD INAF MICROSCOPIC SCREEN IF POSITIVE FOR CORTISOL (FREE) (24h) CORU , BLOOD OR LEUKOCYTE ESTERASE DRUG SCREEN HEMOSIDERIN (Random) HSID MICROSCOPIC SCREEN UR2 SEE DRUG SCREEN REQUISITION 17-KETOSTEROIDS (24h) KS DYSMORPHIC RBC DRBC METABOLIC SCREEN (Random) METU AVAILABLE (0800-1500) REDUCING SUBSTANCES (Random) URS MUST BE ANALYZED WITHIN 1 HR OF COLLECTION UROBILINOGEN (24h) UBGQ SPINAL FLUID SPINAL FLUID PROTEIN PC PROTEIN ELECTROPHORESIS SFPE GLUCOSE GLC OLIGOCLONAL BANDS (Blood Specimen also required) FLUID

INDICATE FLUID SOURCE: *** THESE TESTS REQUIRE PRESERVATIVE WHICH IS URINE ~ ASCITES ~ DIALYSIS ~ PERICARDIAL OBTAINED FROM BIOCHEMISTRY. ~ ~ ~ SODIUM (Random or 24h) NAU SPINAL PERITONEAL PLEURAL VMA, CATECHOLAMINE PERFORMED IF ~ SYNOVIAL ~ OTHER ______POTASSIUM (Random or 24h) KU METANEPHRINES ELEVATED

CHLORIDE (Random or 24h) CLU COLLECTION DETAILS: ______METANEPHRINES*** (24h) MNPH CREATININE (Random or 24h) CRU VMA*** (24h or Timed) VMA TRANSUDATE / EXUDATE EVALUATION: OSMOLALITY (Random or 24h) OSU HOMOVANILLIC ACID*** (24h or Timed) HVA BLOOD MUST BE COLLECTED WITHIN 12 H OF 5HIAA*** (24h) HIAA FLUID COLLECTION CITRATE*** (24h) CITU

AVAILABLE STAT ONLY AFTER PHYSICIAN ~ PLEURAL FLUID EVALUATION: OXALATE*** (24h) OXU HAS CONSULTED THE BIOCHEMIST ON CALL On Blood Order LD & Total Protein PORPHYRINS*** (Random or 24h) POR CREATININE CLEARANCE CRCL PORPHOBILINOGEN*** (Random or 24h) PBG ~ PERITONEAL FLUID EVALUATION: THIS TEST WILL ONLY BE DONE IF HEIGHT AND On Blood Order & Total Protein WEIGHT INFORMATION IS COMPLETED

HEIGHT CM WEIGHT KG PLEURAL FLUID EVALUATION TPFL PERITONEAL FLUID EVALUATION TPFL SODIUM / POTASSIUM / CHLORIDE NAFL/KFL/CLFL FECAL BLOOD MUST BE COLLECTED WITHIN 24 HRS ALBUMIN ALFL REDUCING SUBSTANCES RSF OF URINE COLLECTION BICARBONATE COFL OCCULT BLOOD OB PROTEIN (Random or 24h) TPU BILIRUBIN BFL 72 HOUR FECAL FAT FF ALBUMIN (Random or 24h) UALB CREATININE CRFL START: ______CALCIUM (24h) CAU GLUCOSE GFL FINISH: ______PHOSPHATE (24h) POU LD LDFL UREA (24h) UU LIPASE LPFL URIC ACID (24h) UAU SPECIFIC GRAVITY SGFL TOTAL PROTEIN TPFL UREA UFL CALCULI MISCELLANEOUS URIC ACID UAFL CALCULI CALI FETAL FFN OTHER: ______MSFL SOURCE: IE. BLADDER, RENAL (ATTACH STICKER TO REQUISITION) ______

February 23, 2016 7102-2925-3 TEST REQUISITION BLOOD BIOCHEMISTRY DEPARTMENT As per DSM Specimen Acceptance Policy 10-50-03 - Requirements for Test Requisitions 2.1 - All information marked with an asterisk* is mandatory and must be clearly legible. Failure to comply may result in specimen rejection. ORDERING PROVIDER INFORMATION PATIENT INFORMATION *Last & Full First Name: Billing Code: *Last/First Name: (As per Manitoba Health Card) *Ordering Facility and address: Inpatient Location: *Date of Birth: (dd/mmm/yyyy): *Critical Results Phone No: *Fax No: *SEX q Female q Male *MB PHIN: ADDITIONAL REPORT RECIPIENT PROVIDER INFORMATION - #1 *Alternate ID: (include ID type *Last & Full First Name: Billing Code: with number ie: RCMP, SK, DND, etc) *Ordering Facility and address: MRN: Encounter Number: *Phone No: *Fax No: *Patient Phone No: Demographics verified with: qProvincial Health Card qArmband qeChart/CR ADDITIONAL REPORT RECIPIENT PROVIDER INFORMATION - #2 COLLECTION INFORMATION *Last & Full First Name: Billing Code: *Collector: *Collector D/T: (dd/mmm/yyyy) *Ordering Facility and address: Circle for copy of report YES *Collector Facility: Collected Via: q Venipuncture q Capillary q Indwelling Line q Above Shut Off IV *Fax No: *Phone No: Referring Lab: Number of tubes sent: _____ Circle if samples shipped frozen EDTA _____ SST(gel) _____ Serum (no gel) _____ Citrate _____ Urine _____ AVAILABLE STAT AVAILABLE STAT ONLY AFTER PHYSICIAN HAS CONSULTED THE BIOCHEMIST ON CALL SODIUM NA IONIZED CALCIUM** ICA OTHER DRUGS HORMONES POTASSIUM K AMMONIA** AMM N-DESMETHYLMETHSUXIMIDE* SHBG SHBG CHLORIDE CL L-LACTATE** LAC DMSX DHEA-S DHAS TOTAL CO2 CO2 ETHOSUXIMIDE* ESUX FAI TST+SHBG b-HYDROXYBUTYRATE BHB PRIMIDONE* PRIM FREE T3 FT3 GLUCOSE G CLONAZEPAM* CLON FREE T4 FT4 UREA U GENTAMICIN* GENT CLOBAZAM* CLOB TSH TSH CREATININE CR CARBAMAZEPINE* CARB CYCLOSPORIN* CY THGL PHENOBARBITAL* PHEN TACROLIMUS* FK5 TSH RECEPTOR TSI TOTAL PROTEIN TP PHENYTOIN* PYN AMIODARONE* & NEA AMIO ALBUMIN AL VALPROIC ACID* VALP DISOPYRAMIDE* DISO THYROPEROXIDASE TPO TOTAL CALCIUM CA LIDOCAINE* LIDO (ANTI-TPO) PHOSPHATE P THEOPHYLLINE* TEO MEXILETINE* MXLT ANTI - TG ATHG MAGNESIUM MG DIGOXIN* DIG PROCAINAMIDE* PROC PTH** PTH QUINIDINE* QUIN GROWTH HORMONE GH TOTAL BILIRUBIN TB LITHIUM* LI ANTIBIOTICS MISCELLANEOUS DIRECT BILIRUBIN DB TOBRAMYCIN* TOBR ALDOSTERONE ALDO NEONATAL BILRUBIN INDEX TBI CARBOXYHEMOGLOBIN CBHB VANCOMYCIN* VANC RENIN** REN URIC ACID UA TRICYCLIC ANTI DEPRESSANTS CHOLESTEROL CH LIPASE LIP AMITRIPTYLINE* AMTP TRIGLYCERIDES TG AST AST CLOMIPRAMINE* CLOM LIPID PANEL [ CH, TG, ] LIPP AVAILABLE STAT TO HDL, LDL ALT ALT DESIPRAMINE* DSIP PREALBUMIN PALB EMERGENCY / CRITICAL CARE UNITS LD LD DOXEPIN* DOX HOMOCYSTEINE HCQ CK CK ALCOHOL SCREEN ALC IMIPRAMINE* IMIP FERRITIN FER TROPONIN TNT (INCLUDES: METHANOL, MAPROTILINE* MAP IRON IRON ACETONE, ETHANOL & ONSET OF SYMPTOMS ONST ISOPROPANOL) NORTRIPTYLINE* NRTP TIBC TIBC TIME: ______TRIMIPRAMINE* TRIM METABOLIC SCREEN METS ETHYLENE GLYCOL EGOL Time of Last Feed: ______DATE: ______D / M / Y CLOZAPINE CLOZ a-1-ANTITRYPSIN AIAT a-FETOPROTEIN AFP TRACE METALS CA125 CA1 ALK ALK COPPER** COP HORMONES CA15-3 CA15 gGT GGT ZINC** ZN ACTH** ACTH CA19-9 CA19 CORTISOL COR b-2- BZM ESTRADIOL E2 CARCINOEMBRYONIC ANTIGEN CEA FSH FSH CAROTENE** CARO OSMOLALITY OS LH LH ** CERU ETHANOL ETO PROGESTERONE PGN HEMOGLOBIN A1C HBA1 SALICYLATE SAL PROLACTIN PL VITAMIN B12 B12 ACETAMINOPHEN ACTM PROSTATE SPEC. ANTIGEN PRSA XYLOSE ABSORPTION XTT TESTOSTERONE TST GESTATIONAL DIABETES SCR GT50 BHCG QUANTITATIVE HCGQ GLUCOSE TOLERANCE TEST PREGNANT 2 HR February 23, 2016 7102-2925-3