Page 6 of 43 2020-2021 Laboratory Services Information Manual TEST ORDER ENTRY OUTPATIENTS Laboratory Request Form (Requisition Form) - Physician clients of RCHSD Laboratory are provided with Laboratory Request Forms that contain the physician or practice name and address. Terms in this set (150) CBC. Write. 3. Original Contact Date:_____ MEDIC ID #:_____ (To Be Completed By the Attending Physician ) 1. 6. Mobile phlebotomy is also available for patients if preferred. Therapeutic Phlebotomy Form –This form is used to document a physician’s request for a therapeutic collection. Created by. Fundamentals of phlebotomy. Download Full PDF Package. 97 0 obj
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Requisition Completion, Specimen Labeling and Phlebotomy Guidelines All laboratory testing requires the creation and completion of a visit for the date of the sample collection. Add On Test Fax Form - 20721 (Cross-site); Bacteriology Culture and Serology Requisition CH-0039 (ProvLab North - Edmonton); Bacteriology Requisition - 20691 (ProvLab South - Calgary); Blood and Body Fluid Exposure - 21150 (Cross-site); Bone Marrow Transplant Testing Requisition - 19581 (ProvLab South - Calgary) Therapeutic phlebotomy fees may be applicable for therapeutic collections. College of American Pathologists Revised: 09/27/2007 LABORATORY GENERAL (Web File) Page 4 of 130 GEN.41500 09/27/2007 GEN.41700 09/27/2007 or. 77 0 obj
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4. SOP 1000.02, 1601.00 Page 1 of 1 GC2400 v12 Commit for Life.® Request for Therapeutic Phlebotomy FAX COMPLETED REQUEST TO (713) 790-1782For questions, call (713) 791-6608. All information entered above will then be automatically entered into MOH funding application form. STUDY. General Test Requisition Patient Information ACCT: Last Name First Name MI Male Female D.O.B. Select a suitable site for venipuncture. Prepare the equipment, the patient and the puncture site. Complete the Indiana Consultation Request Form (updated 09/04/19) Call the Reference Lab at 317-916-5188, option 1, to request a courier to pick up the sample ; Requesting Rare Units. Perform the venipuncture, collecting the sample(s) in the appropriate container(s). HOW TO FILL OUT THE REQUISITION FORM STEP 1 . 2"HOW"TO"FILL"OUT"THE"REQUISITION"FORM! 0
Hospital Return (Form) Transfer Components Directly to another Hospital (Procedure) Hospital-to-Hospital Transfer Notice (Form) Report an Issue/Complaint (Procedure) Issue/Complaint Report (Form) Request MIPLATE Apheresis Platelets (Procedure) Boston Children’s Hospital: CTS-5030: MIPLATE PLT Order Form (Form) This paper. It is imperative that LABORATORY REQUEST FORM IN-HOME PHLEBOTOMY (NEW PATIENT) (PLEASE PRINT) ** FAX TO: (781) 322-8032 ** 410 Ferry Street | Malden, Massachusetts 02148 | 781.322.8502 P | 781.322.8032 F PROVIDER INFO: Name: NPI No. W@hO}öÚ�”¼D‹\üÕyó�{Ç®®.Dg¿Fiݲ%}ÊëÔ¡#İKíş«çd¬ÎÚ)&Ä]Á¯eˆ–Ùí
\@üIߨ¦ê�Hiì�«�j5¾+n•—`.~ÀùŞÌä–^Ïâ±qA/÷cÆNïaÛ¸Ÿ9À3sË ‘¾(5—Ì»½Gï.aZÚ¯%’§´‰�iª��ú¬½òêl¦üğ��¶ÁÒ o_ª—î¡–š�£…cM§z£ù´f�r²üõï- Introduction to venipuncture for phlebotomists. Perform the venipuncture. A test requisition form must be submitted for each patient. 7. Prepare the equipment, the patient and the puncture site. LABORATORY REQUEST FORM IN-HOME PHLEBOTOMY (NEW PATIENT) (PLEASE PRINT) ** FAX TO: (781) 322-8032 ** 410 Ferry Street | Malden, Massachusetts 02148 | 781.322.8502 P | 781.322.8032 F PROVIDER INFO: Provider Name: NPI No. Check the requisition form for requested tests, patient information, and any special requirements. Read this manual carefully now and as needed during your enrollment in the Phlebotomy Program. janderr. The following sample test requisition form has been numbered 1 to … Select a suitable site for venipuncture. We apologize that callers may intermittently experience longer than usual wait times. Physician Request Form for Hereditary Hemochromatosis ... For iron depletion, weekly or biweekly whole blood phlebotomy for a total of 10-12 phlebotomies with a serum ... Fax completed form to Blood Bank Transfusion services 978-287-3984; phone 978-287-3360. CLIENT PHLEBOTOMY ORDER FORM Item Description Units Qty. Molecular Otolaryngology & Renal Research Laboratories For test inquiries please call: 319-335-6623 • For billing inquiries call: 319-335-6653 Default will be 12.5 (female)/13.0 (male) whole blood or 13.3 for double red cells, if not specified. endstream
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