COVID-19 Test Requisition (Pharmacy - South Zone)

Edmonton Site 8440-112 St. T6G 2J2 Calgary Site 3030 Hospital Dr NW T2N 4W4 Phone 780.407.7121 Fax 780.407.3864 Phone 403.944.1200 Fax 403.270.2216 Scanning Label or Accession # (lab only) Virologist/Microbiologist-on-call 780.407.8822 Virologist/Microbiologist-on-call 403.944.1200  Consult the Site Virologist/Microbiologist-on-Call listed above for STAT requests, and when specifi ed in the Guide to Services  See the Guide to Services (https://www.albertahealthservices.ca/lab/page3317.aspx/education.htm) for information on sample type, transport and testing

PHN Prov ______Expiry ______Date of Birth (dd-Mon-yyyy)

Legal Last Name Legal First Name Alternate Identifi er

Middle Name Preferred Name Phone Patient  Male  Female  X Non-binary/Prefer not to disclose Address City/Town Prov Postal Code

Authorizing Provider Name Copy to Name (last, fi rst, middle) Copy to Name (last, fi rst, middle)

Address Phone Address Address

Provider(s) Millennium ID Phone Phone

Specimen/Type Source - Specify Date Collected (dd-Mon-yyyy) Time (24 hr) Location Collector ID Outbreak (EI) if applicable (yyyy-###)

Specify Other Serology and Molecular Tests Swab  Nasopharyngeal COVID-19 only   Throat  COVID-19/Respiratory Pathogen Panel Provide Clinical History or Reason for Testing below - Completion of this section is required Reason for Testing List Countries visited within past 3 months of symptom Investigation for COVID-19 exposure onset OR provide relevant travel history Check ONE:  Symptomatic  Asymptomatic  No Travel Date of onset of symptoms (dd-Mon-yyyy) Date of return (dd-Mon-yyyy) Relevant immunizations/dates Immunocompromised  No  Yes (details) ______Consent Contact Preference for COVID-19 Results:  Text  Automated Dialer Phone number: Health Care Worker?  Yes  No Health Care Worker or Resident of LTC/DSL Facility?  Yes  No If yes, specify: Full Facility Name Location Code

Location Code Required (see reverse for list of Codes)

City or Town

21652(2020-09v2) COVID-19 Test Requisition (Pharmacy - South Zone)

If your facility/location is not listed below - please mark “not found in list” on the “Location Code” line.

SouthZone

LTC/DSLFacilityNameLocationCode CityorTown Ambulatory,Emergency,UrgentCareFacilityName LocationCode CityorTown

AgeCareSunriseGardens BRO ASG Brooks BassanoHealthCentreͲAmbulatory BASBHCA Bassano AgeCareValleyview MED ACV MedicineHat BigCountryHospitalͲAmbulatory OYEBCHA Oyen BassanoHealthCentre BAS BHC Bassano BowIslandHealthCentreͲAmbulatory BOWBIHCA BowIsland BigCountryHospital OYE BCH Oyen BrooksHealthCentreͲAmbulatory BROBHCA Brooks BowIslandHealthCentre BOW BIHC BowIsland CardstonHealthCentreͲAmbulatory CRDCHCA Cardston BrooksHealthCentre BRO BHC Brooks ChinookRegionalHospital LETCRH Lethbridge CardstonHealthCentre CRD CHC Cardston CoaldaleHealthCentreAmbulatory COACHCA Coaldale CoaldaleHealthCentre COA CHC Coaldale CrowsnestPassHealthCentreͲAmbulatory BLMCPHCA Blairmore CrowsnestPassHealthCentre BLM CPHC Blairmore FortMacLeodHealthCentreͲAmbulatory FTMFMHCA FortMacleod EdithCavellCareCentre LET ECCC Lethbridge MedicineHatRegionalHospital MEDMHRH MedicineHat ExtendicareFairmontPark LET EFP Lethbridge MilkRiverHealthCentreͲAmbulatory MILMRHCA MilkRiver ExtendicareFortMacleod FTM EFM FortMacleod PincherCreekHealthCentreͲAmbulatory PINPCHCA PincherCreek FortMacLeodHealthCentre FTM FMHC FortMacleod PiyamiHealthCentre PICPHC PictureButte GoodSamaritanGardenVista MAG GSGV Magrath RaymondHealthCentreͲAmbulatory RAYRHCA Raymond GoodSamaritanLeeCrest CRD GSLC Cardston TaberHealthCentreͲAmbulatory TABTHCA Taber GoodSamaritanLindenView TAB GSLV Taber GoodSamaritanParkMeadowsVillage LET GSPMV Lethbridge GoodSamaritanPrairieRidge RAY GSPR Raymond GoodSamaritanSouthRidgeVillage MED GSSRV MedicineHat GoodSamaritanVistaVillage PIN GSVV PincherCreek GoodSamaritanWestHighlands LET GSWH Lethbridge KainaiContinuingCareCentre SDO KCCC StandOff LegacyLodge LET LL Lethbridge LeisureWay MED LW MedicineHat MasterpieceSouthlandMeadows MED MSM MedicineHat MeadowRidgeSeniorsVillage MED MRSV MedicineHat MeadowlandsRetirementResidence MED MRR MedicineHat MilkRiverHealthCentre MIL MRHC MilkRiver PincherCreekHealthCentre PIN PCHC PincherCreek PiyamiPlace PIC PP PictureButte RaymondHealthCentre RAY RHC Raymond RiverRidgeSeniorsVillage MED RRSV MedicineHat RiverviewCareCentre MED RCC MedicineHat St.Joseph'sHome MED SJH MedicineHat St.Michael'sHealthCentre LET SMHC Lethbridge St.ThereseVilla LET STV Lethbridge SunnySouthLodge COA SSL Coaldale SunnysideCareCentre MED SCC MedicineHat TaberHealthCentre TAB THC Taber WellingtonRetirementResidence MED WRR MedicineHat

21652(2020-09v2)