Page 152 - 2019 Surgo Medical Supplies Catalogue.indb

Printing

Ontario Laboratory Requisition Forms

• Printed with physician’s name, address, practitioner and CPSO#
Dr Dr. S. Surgo. S. Surgo
• 8.5” x 11”, black ink only, padded in 100’s Pre-printed -printed
Pre
with Physician’s
183 Simcoe Ave. with Physician’s
183 Simcoe Ave.
Information
Informationrr
Keswick, ON L4P 3S7
Keswick, ON L4P 3S7
650-2005 500 Sheets 100 sheets per pad 85 555-555-5555 555555 555555555555555555555555555555555555555555555555555555555
555-555-5555 555555
$50.
650-2010 1000 Sheets 100 sheets per pad 05
$60.
Biochemistry
650-2020 2000 Sheets 100 sheets per pad 20 x x Biochemistry RandomRandom FastingFasting
G
Glucoselucose
HbA1C
$110. HbA1C
Creatinine (eGFR)
Creatinine (eGFR)
Uric Acid
Uric Acid
Sodium
Sodium
Pt
650-2030 3000 Sheets 100 sheets per pad 95 Potassium i
ALT
Alk. Phosphatase
$159.
Bilirubin
Albumin
Lipid Assessment (includes Cholesterol, HDL-C, Triglycerides,

650-2050 5000 Sheets 100 sheets per pad 25 calculated LDL-C & Chol/HDL-C ratio; individual lipid tests may
be ordered in the “Other Tests” section of this form)
$246. Albumin / Creatinine Ratio, Urine
Urinalysis (Chemical)
Neonatal Bilirubin:
40 Child’s Age: days hours
650-2100 10,000 Sheets 100 sheets per pad Patient’s 24 hr telephone no. ( )
Clinician/Practitioner’s tel. no. ( )
$379. Therapeutic Drug Monitoring:
Name of Drug #1
Name of Drug #2 hr. #2 hr.
Time Collected #1
650-2005D 500 Sheets Duplicating 50 Pairs per pad (100 Sheets) 30 Time of Last Dose #1 hr. hr. #2 #2 hr. hr.
Time of Next Dose #1
$115. I hereby certify the tests ordered are not for registered in or
out patients of a hospital.
650-2010D 1000 Sheets Duplicating 50 Pairs per pad (100 Sheets) 75
$153.
X
Clinician/Practitioner Signature Date
4422-84 (2013/01)
650-2020D 2000 Sheets Duplicating 50 Pairs per pad (100 Sheets) 70
$279.
650-2030D 3000 Sheets Duplicating 50 Pairs per pad (100 Sheets) 90 PLEASE NOTE THAT AS OF 2013,
THE MINISTRY OF HEALTH HAS REMOVED THE
$424.
650-2050D 5000 Sheets Duplicating 50 Pairs per pad (100 Sheets) 30 FOLLOWING TESTS FROM THE FORM:
$658.
650-2100D 10,000 Sheets Duplicating 50 Pairs per pad (100 Sheets) 35 CK, CHLORIDE, FERRITIN, TSH
$1,291.
VITAMIN B12
Please Note: YOU CAN WRITE THESE IN THE
“OTHER TESTS” SECTION
Layout and information stated on form are in accordance with the Ministry of Health and
is subject to change as per their guidelines. We cannot alter the information or layout.
STYLE 22
Letterhead First and Last Name
TITLE Degrees
ADDRESS
CITY, PROVINCE, POSTAL CODE
TELEPHONE
FAX
• 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)
Phone: (H) ___________________________ (B) ______________________________ Next of Kin: _____________________________
• Standard size (8.5” x 11”) DATE
• Printed both sides
Code #
650-101 Generic 1000 Sheets 40
$57.
650-102 Customized - Includes Name 1000 Sheets 55
$147.
We Make it Easy Because
1. Our Prices Include Free Typesetting and Graphic Design
2. Easiest Ordering! Simply fax or email us a copy of your stationary with the
quantity you require. Or visit: www.surgo.com to place your order online.
152 call 1.800.263.7402 click www.surgo.com fax 1.800.663.0395 email sales@surgo.com