COVID-19 Test Requisition (Pharmacy - Central 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

Millennium ID Phone Phone Provider(s)

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

21653(2020-09v2) COVID-19 Test Requisition (Pharmacy - Central Zone) If your facility/location is not listed below - please mark “not found in list” on the “Location Code” line.

CentralZone

LTC/DSLFacilityName LocationCode CityorTown Ambulatory,Emergency,UrgentCareFacilityName LocationCode CityorTown BashawMeadows BSHBM Bashaw ConsortHospitalandCareCentreͲAmbulatory CONCHCCA Consort BentleyCareCentre BENBCC Bentley CoronationHospitalandCareCentreͲAmbulatory CORCHCCA Coronation BethanyCollegeSide REDBC RedDeer DayslandHealthCentre DAYDHC Daysland BethanyMeadows CAMBM Camrose DraytonValleyHospitalandCareCentreͲAmbulatory DRADVHCCA DraytonValley BethanySylvanLake SYLBSL SylvanLake DrumhellerHealthCentreͲAmbulatory DRUDHCA Drumheller BretonContinuingCareCentre BREBCCC Breton HannaHealthCentreͲAmbulatory HANHHCA Hanna ClearwaterCentre RMHCC RockyMountainHouse HardistyHealthCentreͲAmbulatory HARHHCA Hardisty ConsortHospitalandCareCentre CONCHCC Consort InnisfailHealthCentreͲAmbulatory INNIHCA Innisfail CoronationHospitalandCareCentre CORCHCC Coronation KillamHealthCareCentreͲAmbulatory KILKHCCA Killam DrCookeExtendedCareCentre LYDDCECC Lloydminster LacombeHospitalandCareCentreͲAmbulatory LACLHCCA Lacombe DraytonValleyHospitalandCareCentre DRADVHCC DraytonValley LamontHealthCareCentreͲAmbulatory LAMLHCCA Lamont DrumhellerHealthCentre DRUDHC Drumheller OldsHospitalandCareCentreͲAmbulatory OLDOHCCA Olds ExtendicareMichenerHill REDEMH RedDeer OurLadyoftheRosaryHospitalͲAmbulatory CASOLRHA Castor ExtendicareViking VIKEV Viking PonokaHospitalandCareCentreͲAmbulatory PONPHCCA Ponoka GalahadCareCentre GALGCC Galahad ProvostHealthCentreͲAmbulatory PROPHCCA Provost GoodSamaritanGoodShepherdLutheranHome WETGSGSLH Wetaskiwin RedDeerRegionalHospitalCentre REDRDRH RedDeer HannaHealthCentre HANHCC Hanna RimbeyHospitalandCareCentreͲAmbulatory RIMRHCCA Rimbey HardistyHealthCentre HARHHC Hardisty RockyMountainHouseHealthCentre RMHRMHC RockyMtHouse InnisfailHealthCentre INNIHC Innisfail St.Joseph'sGeneralHospital VEGSTJH Vegreville KillamHealthCareCentre KILKHCC Killam St.Mary'sHospital CAMSTMH Camrose LacombeHospitalandCareCentre LACLHCC Lacombe StettlerHospitalandCareCentreͲAmbulatory STESHCCA Stettler LamontHealthCareCentre LAMLHCC Lamont SundreHospitalandCareCentreͲAmbulatory SUNSHCCA Sundre LloydminsterContinuingCareCentre LYDLCCC Lloydminster SylvanLakeCommunityHealthCentre SYLSLCHC SylvanLake LouiseJensenCareCentre CAMLJCC Camrose ThreeHillsHealthCentreͲAmbulatory THRTHHCA ThreeHills MannvilleCareCentre MNVMCC Mannville TofieldHealthCentreͲAmbulatory TOFTHCA Tofield MaryImmaculateCareCentre MUNMICC Mundare TwoHillsHealthCentreͲAmbulatory TWOTTHHCA TwoHills MemoryLane CAMML Camrose VermilionHealthCentreͲAmbulatory VERVHCA Vermilion NorthcottCareCentre PONNCCP Ponoka VikingHealthCentre VIKVHC Viking OldsHospitalandCareCentre OLDOHCC Olds WainwrightHealthCentreͲAmbulatory WAIWHCA Wainwright OurLadyoftheRosaryHospital CASOLRH Castor WetaskiwinHospitalandCareCentreͲAmbulatory WETWHCCA Wetaskiwin ParkAvenueatCreekside RMHPAC RockyMountainHouse PioneerHouse LYDPH Lloydminster PointsWestCenturyPark VEGPWLCP Vegreville PointsWestHeritageHouse VEGPWHH Vegreville PointsWestLivingLloydminster LYDPWLL Lloydminster PointsWestLivingRedDeer REDPWLRD RedDeer PointsWestLivingStettler STEPWLS Stettler PointsWestLivingWainwright WAIPWLW Wainwright PointsWestLivingWetaskiwin WETPWLW Wetaskiwin PonokaHospitalandCareCentre PONPHCC Ponoka ProvostHealthCentre PROPHC Provost RimbeyHospitalandCareCentre RIMRHCC Rimbey RosehavenCareCentre CAMRCC Camrose RoyalOakManor LACROM Lacombe SeasonsCamrose(SunriseVillageCamrose) CAMSVC Camrose SeasonsEncoreOlds(SunriseEncoreOlds) OLDSEO Olds St.Mary'sHealthCareCentre TROSMHCC Trochu StettlerHospitalandCareCentre STESHCC Stettler SundreHospitalandCareCentre SUNSHCC Sundre SundreSeniorsSupportiveLiving SUNSSSL Sundre SunsetManor INNSM Innisfail TheHamletsatRedDeer REDHRD RedDeer ThreeHillsHealthCentre THRTHHC ThreeHills TimberstoneMews REDTM RedDeer TofieldHealthCentre TOFTHC Tofield TwoHillsHealthCentre TWOTTHCC TwoHills VegrevilleCareCentre VEGVCC Vegreville VermilionHealthCentre VERVHC Vermilion VillaMarie REDVM RedDeer WainwrightHealthCentre WAIWHC Wainwright WestParkLodge REDWPL RedDeer WestviewCareCommunity LINWCCC Linden WetaskiwinHospitalandCareCentre WETWHCC Wetaskiwin

21653(2020-09v2)