Regional Virology Laboratory Requisition Form

Virology Laboratory Regional Microbiology Reference Laboratory 401 Smyth Rd, Ottawa ON. K1H 8L1 TEL: 613-737-7600 ext. 2413 FAX: 613-737-4248 NAME: LAST FIRST INITIAL ____________________________________________________________________________ ADDRESS: ___________________________________________________________________________ ____________________________________________________________________________ External Submitter Stamp Here SEX: BIRTHDATE: DD/MM/YYYY _________________________________ ____________________________________________________________ OHCN: ___________________________________________________________ PHYSICIAN: _________________________________________________________________________________________________________________________________________________________________________________________________________ Requesting Physician Relevant ClinicalURINE Diagnosis and History □ BK Virus DNA, Quantitative PCR □ Asymptomatic □ Vomiting □ Rash □ Other: (include travel history) Collection Date/Time: YYYY/MM/DD □ Fever □ Diarrhea □ Neutropenic ___________________________ □ Cough □ Seizures □ Pregnant □ Rhinorrhea □ Headache □ Transplant patient ___________________________ Submitting Lab Accession No. Date of onset of illness: __________________________ ___________________________ Serology Red or SST tube only Measles Mumps Cytomegalovirus Toxoplasmosis Hepatitis A Hepatitis B □ IgG □ IgG □ IgG □ IgG □ IgG □ Surface Antibody (anti-HBs) □ IgM □ IgM □ IgM □ IgM □ Surface Antigen (HBsAg) Rubella Varicella Epstein-Barr Virus Parvovirus Hepatitis C □ Core Total Antibody □ IgG □ IgG □ IgG □ IgG □ Antibody (anti-HBc total) □ IgM □ IgM □ IgM □ IgM PCR Certain requests require Microbiologist approval BLOOD (Red Tube) BLOOD (EDTA Tube) CEREBROSPINAL FLUID (CSF) □ HBV Quantitative □ Adenovirus, Qualitative □ BK Virus, Quantitative □ HSV □ HBV Genotyping □ Parvovirus, Qualitative □ CMV, Quantitative □ VZV □ HCV Quantitative □ Toxoplasma, Qualitative □ EBV, Quantitative □ Enterovirus □ HCV Genotyping □ Other HERPES / ZOSTER PANEL (Swab only) GASTROINTESTINAL PANEL (Stool only) URINE □ HSV/VZV Panel - HSV1, HSV2, VZV □ GI Virus Panel □ BK Virus, Quantitative - Adenovirus (Serotypes 40,41); Astrovirus; Norovirus GI; Specimen type: □ Genital lesion Norovirus GII; Rotavirus; Sapovirus □ CMV, Qualitative □ Skin lesion/aspirate RESPIRATORY PANEL THROAT SWAB (Viral Transport Media) □ Triplex Panel - Flu A; Flu B; RSV Specimen Type: □ Nasopharyngeal Swab □ Mycoplasma pneumoniae □ RV-16 Panel 2 - Adenovirus; Enterovirus; Parainfluenza 1, 2, 3, 4; HMPV □ Auger Suction □ RV-16 Panel 3 - Coronavirus OC43, 229E, NL63; Bocavirus; HBOV; Rhinovirus □ Bronchoalveolar Lavage OTHER TESTING MICROBIOLOGIST APPROVAL AND NOTES _______________________________________ ____________________________ _______________________________________ ____________________________ Specimen Type: ____________________________ ____________________________ .

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