Page 186 - 2021 Surgo Catalogue.indb
P. 186
Lab Requisitions & History Sheets
Ontario Laboratory Requisition Forms
• Printed with physician’s name, address, practitioner and CPSO#
Dr. S. Surgo. S. Surgo
Dr
• 8.5” x 11” Pre-printed re-printed
P
with Physician’s
183 Simcoe Ave. with Physician’s
183 Simcoe Ave.
Informationrr
• Black ink only Keswick, ON L4P 3S7 Information
Keswick, ON L4P 3S7
• Padded in 100’s
555-555-5555 555555 555555555555555555555555555555555555555555555555555555555
555-555-5555 555555
650-2005 500 Sheets 100 sheets per pad $50.85
Biochemistry
x x Biochemistry
650-2010 1000 Sheets 100 sheets per pad $60.05 G Glucoselucose RandomRandom FastingFasting
HbA1C
HbA1C
Creatinine (eGFR)
Creatinine (eGFR)
Uric Acid
Uric Acid
Sodium
Sodium i
Potassium
Pt
650-2020 2000 Sheets 100 sheets per pad $110.20 ALT Alk. Phosphatase
Bilirubin
Albumin
Lipid Assessment (includes Cholesterol, HDL-C, Triglycerides,
650-2030 3000 Sheets 100 sheets per pad $159.95 calculated LDL-C & Chol/HDL-C ratio; individual lipid tests may
be ordered in the “Other Tests” section of this form)
Albumin / Creatinine Ratio, Urine
Urinalysis (Chemical)
Neonatal Bilirubin: days hours
Child’s Age:
650-2050 5000 Sheets 100 sheets per pad $246.25 Clinician/Practitioner’s tel. no. ( )
Patient’s 24 hr telephone no. ( )
Therapeutic Drug Monitoring:
Name of Drug #1
Name of Drug #2
650-2100 10,000 Sheets 100 sheets per pad $379.40 Time Collected #1 hr. hr. #2 #2 hr. hr.
Time of Last Dose #1
#2
hr.
Time of Next Dose #1
I hereby certify the tests ordered are not for registered in or hr.
out patients of a hospital.
650-2005D 500 Sheets Duplicating 50 Pairs per pad (100 Sheets) $115.30
650-2010D 1000 Sheets Duplicating 50 Pairs per pad (100 Sheets) $153.75 X Clinician/Practitioner Signature Date
4422-84 (2013/01)
650-2020D 2000 Sheets Duplicating 50 Pairs per pad (100 Sheets) $279.70 PLEASE NOTE THAT AS OF 2013,
650-2030D 3000 Sheets Duplicating 50 Pairs per pad (100 Sheets) $424.90 THE MINISTRY OF HEALTH HAS REMOVED THE FOLLOWING TESTS
FROM THE FORM:
650-2050D 5000 Sheets Duplicating 50 Pairs per pad (100 Sheets) $658.30
CK, CHLORIDE, FERRITIN,
650-2100D 10,000 Sheets Duplicating 50 Pairs per pad (100 Sheets) $1,291.35 TSH, and VITAMIN B12
YOU CAN WRITE THESE IN THE “OTHER TESTS” SECTION
Letterhead
First and Last Name
Degrees
TITLE
• Standard size (8.5” x 11”) CITY, PROVINCE, POSTAL CODE
ADDRESS
TELEPHONE
FAX
Letterhead
STYLE 22
• Standard size (8.5” x 11”)
Code #
650-400.20 Black Ink 24lb Bond 1000 Sheets 75
$ 99.
650-400.55 Black Ink Strathmore 1000 Sheets 25
$229.
650-400.56 Coloured Ink 24lb Bond 1000 Sheets 40
$247.
650-400.57 Coloured Ink Strathmore 1000 Sheets 70
$350.
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
Code #
650-101 Generic 1000 Sheets 40
$ 57.
650-102 Customized - Includes Name 1000 Sheets 55
$147.
186 call 1.800.263.7402 click www.surgo.com fax 1.800.663.0395 email sales@surgo.com
