Page 178 - Surgo Catalogue 2024 Medical Supplies and Equipment

History Sheets

Ontario Laboratory Requisition Forms

• Printed with physician’s name, address, practitioner and CPSO#
. S. Sur
Dr Dr. S. Surgo go
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p
re
Pre-printed
P
• 8.5” x 11” 183 Simcoe Ave. with Physician’s
e
d
rint
with Physician’s
183 Simcoe Ave.
Information
r
r
Information
Keswick, ON L4P 3S7
• Black ink only Keswick, ON L4P 3S7
• Padded in 100’s 555-555-5555 555555 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
5
555-555-5555 555555
650-2005 Standard Forms 500 Sheets $ 54.00
Biochemistry
x x Biochemistry
G Glucoselucose RandomRandom FastingFasting
HbA1C
HbA1C
650-2010 Standard Forms 1000 Sheets $ 64.00 Creatinine (eGFR)
Creatinine (eGFR)
Uric Acid
Uric Acid
Sodium
Sodium
Pt
Potassium i
ALT Alk. Phosphatase
650-2020 Standard Forms 2000 Sheets $116.00 Bilirubin
Albumin
Lipid Assessment (includes Cholesterol, HDL-C, Triglycerides,
calculated LDL-C & Chol/HDL-C ratio; individual lipid tests may
be ordered in the “Other Tests” section of this form)
650-2030 Standard Forms 3000 Sheets $169.00 Albumin / Creatinine Ratio, Urine
Urinalysis (Chemical)
Neonatal Bilirubin:
Child’s Age: days hours
Clinician/Practitioner’s tel. no. ( )
Patient’s 24 hr telephone no. ( )
650-2050 Standard Forms 5000 Sheets $259.00 Therapeutic Drug Monitoring:
Name of Drug #1
Name of Drug #2
Time Collected #1 hr. #2 hr.
Time of Last Dose #1 hr. hr. #2 #2 hr. hr.
Time of Next Dose #1
650-2100 Standard Forms 10,000 Sheets $399.00 I hereby certify the tests ordered are not for registered in or
out patients of a hospital.
650-2005D Duplicating Forms 500 Sheets $118.85
X
Clinician/Practitioner Signature Date
4422-84 (2013/01)
650-2010D Duplicating Forms 1000 Sheets $158.45
650-2020D Duplicating Forms 2000 Sheets $288.15 PLEASE NOTE THAT THE MINISTRY OF HEALTH
650-2030D Duplicating Forms 3000 Sheets $437.70 HAS REMOVED THE FOLLOWING TESTS
FROM THE FORM:
650-2050D Duplicating Forms 5000 Sheets $678.10
CK, CHLORIDE, FERRITIN,
650-2100D Duplicating Forms 10,000 Sheets $1,330.15
TSH, and VITAMIN B12
YOU CAN WRITE THESE IN THE “OTHER TESTS” SECTION
Letterhead
First and Last Name
Degrees
• Standard size (8.5” x 11”) TITLE ADDRESS
CITY, PROVINCE, POSTAL CODE
TELEPHONE
FAX
STYLE 22
650-400.20 Black Ink 24lb Bond 1000 Sheets $105.00
650-400.55 Black Ink Strathmore 1000 Sheets $236.20
650-400.56 Coloured Ink 24lb Bond 1000 Sheets $253.00
650-400.57 Coloured Ink Strathmore 1000 Sheets $358.00
History Sheets Name: _________________________________________________ Sex: ____ D.O.B.: __________________ File #: _________________

(DD/MM/YY)
Health Card Number: ___________________________________________ Allergies;________________________________________
Mailing Address: __________________________________________________________________________________________________
(City) (Province) (Postal Code)
• Standard size (8.5” x 11”) Phone: (H) ___________________________ (B) ______________________________ Next of Kin: _____________________________
• Printed both sides DATE
650-101 Generic - 2 Sided 1000 Sheets $ 61.00
650-102 Customized Includes Name - 1 Side 1000 Sheets $156.00

178 call 1.800.263.7402 click www.surgo.com fax 1.800.663.0395 email sales@surgo.com