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 DNA, Quantitative PCR □ □ Vomiting □ Rash □ Other: (include travel history) □ Fever □ Diarrhea □ Neutropenic ______Collection Date/Time: YYYY/MM/DD □ Cough □ Seizures □ Pregnant □ Rhinorrhea □ Headache □ Transplant patient ______Submitting Lab Accession No. Date of onset of illness: ______

Serology Red or SST tube only

Measles Toxoplasmosis □ IgG □ IgG □ IgG □ IgG □ IgG □ Surface Antibody (anti-HBs) □ IgM □ IgM □ IgM □ IgM □ Surface Antigen (HBsAg)

Rubella Varicella Epstein-Barr Virus Parvovirus □ 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); ; GI; Specimen type: □ Genital lesion Norovirus GII; ; 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 - OC43, 229E, NL63; Bocavirus; HBOV; Rhinovirus □ Bronchoalveolar Lavage

OTHER TESTING MICROBIOLOGIST APPROVAL AND NOTES ______Specimen Type: ______