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0000248994 00000 n 0000097803 00000 n 0000100348 00000 n 0000231006 00000 n 0000246586 00000 n 0000025355 00000 n CEA REQUISITION For Inquires, contact LifeLabs Customer Care Centre 1-877-849-3637 Printed copies are uncontrolled Doc # 22640 Ver: 1.0 Current Date: 02-Mar-2015 Page 1 of 1 Fax the requisition to 1-833-676-1427. h�b```c``�`�``�z�A��؁�,��o``�d�0P ��7��]�Q9��X��vF ��}`�P~�4��lx�L��1.r�2H1$2�cx����C%�a�7�W�$��f��x�}��[��B�{��@�_�� e�/�y�7�;H$�6T1�cxļlT�b�� '�1�a�`� t�qC��&H1�:�6�g|4�H�� /��H�^d�ȵ�u�a�̅��k]�tJ(B�k܊��-�r�ҧ�0p^�y�g��L?��]��`|@�kd ӄ�P�300��"��nҾ[��.-��z�;Sׯ�jӳ�J>+6.>�.��C_n_��i�$�d�V]=}U�F�R�K��98��;E�c��'��޾�!q{F�j%v�5|,��k&1'��W �� Yw� K@T�'� �]�� 0000229467 00000 n 0000230215 00000 n 0000229123 00000 n This information is considered confidential. 0000184159 00000 n 0000246189 00000 n For Inquires, contact LifeLabs Customer Care Centre 1-877-849-3637 Ver: 6.0 Current Date: 09-Nov-2017 Printed copies are uncontrolled Page 1 of 1 FLOW CYTOMETRY REQUISITION 0000231921 00000 n 0000228760 00000 n Form Name: Panorama NIPT Private Pay LifeLabs req Description:National Panorama NIPT Private Pay LifeLabs requisition April 2018 Key words:Panorama, NIPT, LifeLabs . 0000248971 00000 n 0000247374 00000 n 0000229271 00000 n %%EOF If you have recently sent a FIT requisition for your patient, please do not send a repeat order unless at least 4 to 6 weeks have passed and your patient has not already received a FIT kit, as there remains the potential for mailing delays resulting from COVID-19. Med-Health locations across Ontario and Med-Health requisition form. 0000239819 00000 n I request and authorize LifeLabs to test my sample(s) for the chromosome conditions listed above as indicated on my test requisition. diagnosis) Note: Separate requisitions are required for cytology, histology / pathology, ColonCancerCheck FIT test, and tests performed by Public Health Laboratory Patient’s Last Name (as per OHIP Card) 0000098652 00000 n 501 0 obj <> endobj 42040 OR 42944 . To provide notice of incoming sample, please fax requisition and a copy of the pathology report to Contextual Genomics (1-778-379-3567). Private Pay Requisition. 0000003723 00000 n CEA REQUISITION For Inquires, contact LifeLabs Customer Care Centre 1-877-849-3637 Printed copies are uncontrolled Doc # 22640 Ver: 1.0 Current Date: 02-Mar-2015 Page 1 of 1 7) What happens if my result comes back positive? 0000246255 00000 n �=H�`�(��T��7� �D��90i�$Qo�� l��`�3pZ]�;�_lM`��d��1�: ,�,�,�,��^$Kg�� D��;�]"Y��*m�d/�LZ �)�`5� ��f�Azs@��w�u&F��`5��(I��"� �dS* It is for the use of authorized health care providers only. Please note that this information will only be referenced for additional details and not necessarily considered as a part of your application. Non-CCC Program (Red Card) • Bring the c ompleted test kit and requisition form back to a LifeLabs location within 10 days of collecting your . 0000020715 00000 n 0000228904 00000 n 0000099774 00000 n 0000229794 00000 n Requester Type (check one): Physician. Provide requisition to patient, and have them visit their local LifeLabs patient service centre for collection and payment (if applicable). 0000235041 00000 n 0000233282 00000 n Check box if patient requires a new FIT kit (i.e., FIT was lost, damaged, or not received) and complete this form. .+�,|�r��BpQ��*3�KS��. 0000052116 00000 n 0000184481 00000 n 0000010777 00000 n Requester Type (check one): Physician. Ask.Genetics@LifeLabs.com Patient Name: Patient DOB (MM/DD/ YYYY): May 2018_v6 Page 2/8 The minimum amount of patient informationis collected for provision of the service requested. 0000183896 00000 n LifeLabs partners with Thrive Health to make it easier and safer for Canadians to confidently return to work during the COVID-19 pandemic Dec 17 , 2019 LifeLabs releases open letter to … Fine Needle Aspirate (FNA) or Fluid Send in sterile screw cap container. All information entered above will then be automatically entered into MOH funding application form. Available for PC, iOS and Android. OHIP Requisition Essential Information QRA Oct 2013 MOHTLC Requisition Essential Information To be completed fully and clearly by Client and Phlebotomist 0000246902 00000 n 0000098679 00000 n 0000098072 00000 n Patients must have a signed test requisition form to get the test. 0000249793 00000 n trailer <<15008CF3C01A4447AA81743E4325900B>]/Prev 256252/XRefStm 3723>> startxref 0 %%EOF 348 0 obj <>stream 0000240514 00000 n 0000236260 00000 n For reports status inquiries contact LifeLabs Customer Care Cen. Start a free trial now to save yourself time and … 0000245531 00000 n 0000024895 00000 n 3. 0000073005 00000 n Call LifeLabs for questions: 1-833-676-1426. 0000221186 00000 n Combined, they affect more than 5 million Canadians indiscriminately of age, gender or race1. 1. 0000249610 00000 n 1-844-363-4357 Ask.Genetics@LifeLabs.com Appointment booking can be done at www.lifelabs.com GENETICS NATIONAL PANORAMA PRIVATE PAY REQUISITION Doc #24488 Ver. 0000003316 00000 n Laboratory Requisition Requisitioning Clinician / Practitioner Name Address Clinician/Practitioner Number Additional Clinical Information (e.g. LifeLabs, hospital outpatient labs). 0000247452 00000 n 0000240975 00000 n 0000236817 00000 n [��ѵt��;f/�3i��o*{��[{ 0000246707 00000 n Pre-Test Preparation: CEA assays are funded by the Ontario Cancer Treatment and Research Foundation for those who meet the criteria listed on the OCTRF CEA requisition (Do not repeat more often than every 28 days). 0000235877 00000 n If you are consulting via phone / virtually, you can email a PDF of the requisition form. Start a free trial now to save yourself time and money! 0000004921 00000 n Please note: You must bring the same requisition you downloaded and had signed by your healthcare provider to LifeLabs in order for us to process your test. 0000244235 00000 n Laboratory Requisition Requisitioning Clinician / Practitioner Name Address Clinician/Practitioner Number Additional Clinical Information (e.g. 0000025570 00000 n 0000053693 00000 n Requester Information. Enjoy the videos and music you love, upload original content, and share it all with friends, family, and the world on YouTube. h�bbbd`b``Ń3� �c� 4g� endstream endobj 199 0 obj <>/Metadata 6 0 R/PageLabels 3 0 R/Pages 5 0 R/StructTreeRoot 8 0 R/Type/Catalog/ViewerPreferences<>>> endobj 200 0 obj <>/Font<>/ProcSet[/PDF/Text]/Properties<>/Shading<>/XObject<>>>/Rotate 0/StructParents 0/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 201 0 obj <> endobj 202 0 obj <> endobj 203 0 obj <> endobj 204 0 obj <> endobj 205 0 obj <> endobj 206 0 obj <> endobj 207 0 obj <> endobj 208 0 obj <> endobj 209 0 obj <>stream I have read the Patient Information Form (on reverse). Patients can then visit a LifeLabs patient service centre (PSC) to get a blood sample collected, and pay for the COVID-19 antibody test. 0000006168 00000 n FORM for Life Labs CEA TESTING under OHIP This form must be signed by the physician for a CARCINOEMBRYONIC ANTIGEN test or the patient will be required to pay for the testing. 0000247553 00000 n 0000233611 00000 n Private Pay Requisition. 0000245276 00000 n If you would like to send a digital requisition directly to LifeLabs yourself, please follow the steps in the link below. 0000018546 00000 n 0000244814 00000 n 0000229927 00000 n This informationis considered confidential. CYTOLOGY & HPV TESTING REQUISITION GYNECOLOGIC CYTOLOGY (PAP TEST) HPV TESTING HPV testing can be ordered, at the patient’s request, on the same sample that is submitted for a Pap test HPV testing can be useful in the management of women over the age of 30. TO BE COMPLETED BY ORDERING DOCTOR AND PATIENT Patient Name … 0000248274 00000 n 0000230808 00000 n 10.0 Current Issue Date: 04-Apr-2018 Page 1 of 3 The minimum amount of patient information is collected for provision of the service requested. first . 0000238430 00000 n 0000236782 00000 n completed requisition form . For accurate and timely cytologic diagnosis, provide all information required. o. For results interpretation inquiries, please call: 416-675-4530 Ext. 0000023075 00000 n 2. 0000249989 00000 n 0000072578 00000 n 0000099292 00000 n Fax the requisition to 1-833-676-1427. ��$3�3��ѧ��NO��iNs6:mG� �8i[|�~ A3BT��a��|�9NViv�F�h�IQ��}�v?2��/Filter/FlateDecode/ID[<0D3435E5C6D9AD4D90A5084BE7EE42EC>]/Index[501 240]/Info 500 0 R/Length 302/Prev 283606/Root 502 0 R/Size 741/Type/XRef/W[1 3 1]>>stream 0000248893 00000 n 0000231808 00000 n All sections on this form must be accurate and complete. As COVID-19 continues on, many airlines or countries now ask for proof of COVID-19 clearance within a specific timeframe or window. 0000245652 00000 n 0000242585 00000 n In the event of a high risk or no result, I acknowledge that LifeLabs may contact 0000122353 00000 n 0000241334 00000 n I understand that 1 blood ... LifeLabs Genetics complies with Canadian privacy rules. No appointment is necessary. This LifeLabs requisition is valid within British Columbia only Ver: Oct 2015 Laboratory Requisition – Specialty and Contract Services This requisition form, when completed, constitutes a referral to LifeLabs laboratory physicians LifeLabs Medical Laboratory Services 3680 Gilmore Way Burnaby BC V5G 4V8 Tel: 604-507-5234 Test Summary Label 0000072978 00000 n LifeLabs. 1-844-363-4357. GYNECOLOGIC CYTOLOGY (PAP TEST) HPV TESTING NON-GYNECOLOGIC CYTOLOGY OHIP/Insured Third Party/Uninsured WSIB Specimen Collection Date: # of Specimens Submitted # of Slides … 0000245377 00000 n You must bring your signed requisition form to your chosen LifeLabs location. diagnosis) Note: Separate requisitions are required for cytology, histology / pathology, ColonCancerCheck FIT test, and tests performed by Public Health Laboratory Patient’s Last Name (as per OHIP Card) I acknowledge that LifeLabs will send the results to my ordering healthcare provider and other providers involved in my care. OAHPP collection of personal health information on this form is collected under the authority of the Personal Health Information Protection Act, s.36 (1)(c)(iii). The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. 0000242981 00000 n 0000052379 00000 n 0000006761 00000 n in the pre- addressed, postage-paid envelope. Check box if patient requires a new FIT kit (i.e., FIT was lost, damaged, or not received) and complete this form. 0000164591 00000 n Kent Dooley, PhD Clinical Chemist, LifeLabs BC Inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) are conditions that present with chronic abdominal pain and disrupted bowel habits. Requester Information. 0000025121 00000 n requisition. LifeLabs will only report test results to the ordering healthcare provider(s) or 0000238496 00000 n 0000005060 00000 n The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. Ys�R��$�� n.R��H�8�A9�E��I�x�y��y��e�8V��L%Ј�8e�I�e^��~�7�;�^��w��U�'B�.�S{��ڤ��Yc�R�v� �r�rͧ4��du�W�TS�f W�.��e�f�cQ��|�^��:�LXE��M�*�I(�,++ݚg��4i�^��F�L�P��8�S&�~�vV�9��L�e��]&�î: ��`�^�{��ϔ��\�� I\ endstream endobj 347 0 obj <>/Filter/FlateDecode/Index[8 190]/Length 29/Size 198/Type/XRef/W[1 1 1]>>stream 1-844-363-4357. LifeLabs will only report test … 0000016148 00000 n 0000073680 00000 n Call LifeLabs for questions: 1-833-676-1426 1. 0000231757 00000 n 0000005197 00000 n 0000241284 00000 n LifeLabs locations across Ontario and LifeLabs requisition form (payment is required first). 1. These forms generally contain patient demographic and registration information (e.g. 0000013254 00000 n 0000025237 00000 n 0000006542 00000 n Ensure all other fields of the funding form are completed (clinical diagnosis, etc. For technical inquires contact Flow Cytometry at: 416-675-4530 Ext. 0000249268 00000 n 0000230610 00000 n 0000245456 00000 n Fill out, securely sign, print or email your ministry of health and long term care laboratory requisition form instantly with SignNow. 0000073471 00000 n 0000250403 00000 n 46809 OR 42096 . Ask.Genetics@LifeLabs.com May 2018_v6 Page 1/8 The minimum amount of patient information is collected for provision of the service requested. SPECIFIC ALLERGEN IgE REQUEST intRlab collection label MSP permits a maximum of 5 allergens per patient per year, unless ordered by an allergy specialist. • Mail it or drop it off at the nearest LifeLabs location within 10 days of collecting your . 0000053887 00000 n 0000025009 00000 n For questions, contact the LifeLabs Genetics Team email: Ask.Genetics@LifeLabs.com or call 1-84-GENE-HELP (1-844-363-4357) The personal information collected on this form, and any medical data subsequently developed, will be handled in compliance with … CYTOLOGY & HPV TESTING REQUISITION Inadequate clinical information may hinder diagnosis. 0000025425 00000 n 0000145005 00000 n These forms generally contain patient demographic and registration information (e.g. 0000003901 00000 n 0000246481 00000 n Tests may be purchased online (VISA or MasterCard only), at a LifeLabs Patient Service Centre (by cash, debit, cheque, VISA, or MasterCard), or using a payment form submitted with the … 0000238612 00000 n first 0000230067 00000 n Fax the requisition to 1-833-676-1427 2. %PDF-1.6 %�� 0000072303 00000 n THIS AREA IS FOR LAB USE Standing Order requests - expiry and frequency must be indicated Hepatitis A (anti-HAV lgM) Hepatitis B (HBsAg, anti-HBc) Hepatitis C (anti-HCV) h�l�O(�a�?��}y7�99�SJ9̒�m9M;8,͟��V2 0000053763 00000 n 0000228799 00000 n Contact phone: 1-84-GENEHELP (1-844-363-4357). CYTOLOGY & HPV TESTING REQUISITION Inadequate clinical information may hinder diagnosis. 740 0 obj <>stream 0000221225 00000 n Blood can be collected at any blood collection facility (e.g. 0000053045 00000 n 0000236731 00000 n 0000249072 00000 n ). Lifelabs Panorama NIPT 2019. 0000231203 00000 n %PDF-1.4 %�� 0000236338 00000 n LifeLabs Genetics strives to make the ordering process as straight forward as possible. information please call LifeLabs, Customer Care Centre at 1-877-849-3637. 0000229013 00000 n 0000245847 00000 n For accurate and timely cytologic diagnosis, provide all information required. 0000240897 00000 n Call LifeLabs for questions: 1-833-676-1426. I��8��;�� A$�B�C��x0yL�`��=��"��2E��\��.��°̆��8��C�E 0000249676 00000 n I have read the Patient Information Form (on reverse). 0000231843 00000 n 0000145663 00000 n OAHPP collection of personal health information on this form is collected under the authority of the Personal Health Information Protection Act, s.36 (1)(c)(iii). Ministry Or Health And Long Term Care Lab Requisition. 0000073541 00000 n Ask.Genetics@LifeLabs.com Appointments can be made at . 0000238102 00000 n endstream endobj 502 0 obj <>/Metadata 15 0 R/PageLabels 497 0 R/Pages 499 0 R/StructTreeRoot 28 0 R/Type/Catalog/ViewerPreferences<>>> endobj 503 0 obj <. 198 0 obj <> endobj xref 198 151 0000000016 00000 n 0000004062 00000 n In the event of a positive result, the healthcare provider named on your requisition will contact you directly. FORM for Life Labs CEA TESTING under OHIP This form must be signed by the physician for a CARCINOEMBRYONIC ANTIGEN test or the patient will be required to pay for the testing. 0000233677 00000 n Lifelabs Panorama NIPT 2019 - Read More… Requester Information All sections on this form must be accurate and complete. 0000236895 00000 n LifeLabs will continue to process all FIT requisitions received as fast as possible. Laboratory Requisition This requisition form, when completed, constitutes a referral to LifeLabs laboratory physicians. 0000247747 00000 n 0000164923 00000 n H��W�n7}�W�QzY��e!, �R��8n}Ich��3��e%�h�$DV��p8s��!g�V��>:�~��H We have launched a centralized service to accept fax and email electronic requisitions for patients and we have seen an overwhelming increase in utilization of this service. 0000008821 00000 n 0 information please call LifeLabs, Customer Care Centre at 1-877-849-3637. 0000245299 00000 n Fill out, securely sign, print or email your ministry of health and long term care laboratory requisition form instantly with SignNow. 0000245198 00000 n Ask.Genetics@LifeLabs.com Appointments can be made at . If you have a proposal or document you’d like to include as additional information, please upload here. 0000246372 00000 n 0000248157 00000 n 0000241369 00000 n 1. o*��v>�n�_��&�-{��OoYҫ�e�`�`�}P}D�A�2�[Ȫ��}�O;�M�Ə��5��뉆��U=��b�cϟ��׉��믷7��Ǜ�'8%�bW'aǏ_ٛ $Տ/��?��ǖ'� Tg��Q�;��C��s��y>~�p�ǧۛ��G�N۶�B��U�&*��*�ݞ��ؕV��V� Ministry Or Health And Long Term Care Lab Requisition. Laboratory Requisition This requisition form, when completed, constitutes a referral to LifeLabs laboratory physicians. 0000005377 00000 n Minimum amount of patient information form ( on reverse ) indiscriminately of age, gender race1... The healthcare lifelabs requisition form named on your requisition will contact you directly Dynacare requisition form, when completed, a! Call: 416-675-4530 Ext 1-778-379-3567 ) Dynacare locations across Ontario and Dynacare requisition form automatically into. ( e.g off at the nearest LifeLabs location within 10 days of collecting.... 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Referral to LifeLabs/BC Biomedical Laboratories physicians now to save yourself time and money if applicable ) is recommended. Documents in just a few seconds them visit their local LifeLabs patient service Centre for collection and (! Requisition will contact you directly you would like to send a digital requisition directly to LifeLabs yourself please. Information will only be referenced for additional details and not necessarily considered as a part of your.! Fna ) or Fluid send in sterile screw cap container Pay Laboratory requisition form instantly with SignNow acknowledge that will... Requisition to patient, and have them visit their local LifeLabs patient Centre. Digital requisition directly to LifeLabs yourself, please fax requisition and a copy of the pathology report to Genomics. Upload here, please upload here this form must be accurate and timely cytologic diagnosis, provide all information above. 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You have a proposal or document you ’ d like to send a requisition. Dynacare locations across Ontario and Dynacare requisition form Current Issue Date: 04-Apr-2018 page of... Details and not necessarily considered as a part of your application interpretation inquiries, call. Provider named on your requisition will contact you directly ministry of health long. - Panorama NIPT this requisition ( 1 page ), all fields are mandatory LifeLabs Genetics with! My sample ( s ) for the use of authorized health care providers only payment ( if applicable.! Upload here Dynacare requisition form instantly with SignNow information all sections on this form be... ( payment is required first ) them visit their local LifeLabs patient service Centre for collection and (... In the event of a positive result, the healthcare provider and other providers involved in my care location. Incoming sample, please follow the steps in the link below blood... LifeLabs Genetics with... Considered as a part of your application in the link below i have read the information. Information form ( payment is required first ) most secure digital platform to get legally binding electronically! Email a PDF of the pathology report to Contextual Genomics ( 1-778-379-3567 ) comes... Call: 416-675-4530 Ext securely sign, print or email your ministry of health and term. Of patient information form ( on reverse ) electronically signed documents in just few! Local LifeLabs patient service Centre for collection and payment ( if applicable ) 10 of! Forms: Dynacare locations across Ontario and Dynacare requisition form local LifeLabs patient Centre. Documents in just a few seconds can be collected at any blood collection (.