[PDF] Requisition for Specimen Containers and Supplies - Public Health

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Requisition for Specimen Containers and Supplies

Customer no.:

Please note:

Specimen containers and supplies are supplied to submitters exclusively for samples that are to be tested by the

Public Health Ontario Laboratories.

Current version of Public Health Laboratory requisitions are available a t www.publichealthontario.ca/requisitions.

Requisitioner's name:Telephone no.:

Date:Fax no.:Authorized Signature:Ship to (include Client name, Address and Postal code):NameKitsItem #UoMQuantityChlamydia

trachomatis & Neisseria gonorrhoeae

NAA testingRoche cobas

PCR Urine Sample kit300316Box of 100

Roche cobas

PCR Media Dual Swab

Sample kit300317Box of 100

DFDirect Fluorescence390047EA.

Enteric

Outbreak kit2 vials: Green-Enteric Bacteriology and White-Virology / Toxin testing390036EA.

FAECES

Enteric Bacteriology - Health Units Only

(Cary Blair)390049EA.

GLGastric Lavage - M. tuberculosis390043EA.

PARAFaeces - Routine Parasitology390033PKG / 3

TB (90 ml sterile container)390042EA. CD (90 ml sterile container)390054EA.

Virus Culture

(tissue)

Universal Transport Media (UTM)390075EA.

Water

Private Citizen Water - bacteriological390040EA.

Sterile - Water bottles - 250 ml

300013EA.

PWO kitPinworm Ova Kit390045EA.

BL-S

Blood, clotted

Serology - Syphilis / Virus / Other390044PKG / 6

BPBordetella pertussis (Whooping cough)390052PKG / 2

CHL(C)

Female

, Chlamydia trachomatis culture (Universal Transport Media-UTM)

390083PKG / 6

Male , Chlamydia trachomatis culture (Universal Transport Media-UTM)

390084PKG / 6

MP / CP - Resp

Mycoplasma pneumoniae /

Chlamydophila pneumoniae - Respiratory390085PKG / 6 F dermatophyte)390048PKG / 6

GCNeisseria gonorrhoeae culture390051PKG / 6

MP

Genital Mycoplasma / Ureaplasma culture

(Universal Transport Media-UTM)390064PKG / 6 PrenatalRubella, Syphilis, Hep.B, HIV390050PKG / 6

Virus Culture

- Herpes / STISwab in transport medium (Universal Transport Media-UTM)390081PKG / 6

Virus -

Respiratory

Nasopharyngeal swab in transport

medium (Universal Transport Media-UTM)390082PKG / 6

Virus - Enteric

Virus culture/electron microscopy /

PCR & direct antigen testing390087PKG / 6 DescriptionItem#UoMQuantity

Clinical

Specimens (Self-Seal)300008PKG / 100

Test Requisition Bacterial

Analysis of Water

(Private Citizen - single sample) (Form # 3743-44)300087PKG / 100

Test Requisition Bacterial

Analysis of Water

sample) (Form # 4321-44)

300089PKG / 100

General Test Requisition

(Form # 97-44) PHL300122PKG / 100

Test Requisition Prenatal

(Form # 1739-44)

300086PKG / 100

Comments:

Date order received (yyyy/mm/dd):

Date order shipped (yyyy/mm/dd):

F-SD-SCG-1003-009

Hamilton250 Fennell Avenue West

Box 2100

Hamilton ON L8N 3R5

Tel.: 905 385-5379

Fax: 905 385-0083

Toll free: 1-866-282-7376

Kingston181 Barrie Street

Box 240

Kingston ON K7L 4V8

Tel.: 613 548-6630

Fax: 613 547-1185

Toll free: 1-855-546-4745

LondonUnit 102,

1200 Commissioners Rd. East,

London, ON N5Z 4R3

Tel.: 519 455-9310

Fax: 519 455-3363

Toll free: 1-877-204-2666

Orillia750 Memorial Avenue

Box 600

Orillia ON L3V 6K5

Tel.: 705 325-7449

Fax: 705 329-6001

Toll free: 1-877-611-6998

Ottawa2380 St. Laurent Boulevard

Ottawa ON K1G 6C4

Tel.: 613 736-6800

Fax: 613 736-6820

Peterborough99 Hospital Drive

Box 265

Peterborough ON K9J 6Y8

Tel.: 705 743-6811

Fax: 705 745-1257

Sault Ste. Marie160 McDougald Street

Sault Ste. Marie ON P6A 3A8

Tel.: 705 254-7132

Fax: 705 945-6873

Toll free: 1-800-263-0409

Sudbury1300 Paris Street

Suite 2

Sudbury ON P3E 6H3

Tel.: 705 564-6917

Fax: 705 564-6918

Toll free: 1-888-564-6917

Thunder Bay336 South Syndicate Avenue

Thunder Bay ON P7E 1E3

Tel.: 807 622-6449

Fax: 807 622-5423

Timmins67 Wilson Avenue

Timmins ON P4N 2S5

Tel.: 705 267-6633

Fax: 705 360-2006

Toll free: 1-888-267-7181

F-SD-SCG-1003-009 www.publichealthontario.ca

Customer

Service Centre

General inquiriesEmail: customerservicecentre@oahpp.ca

Tel.: 416 235-6556

Toll-free: 1-877-604-4567

Public Health Laboratories

Toronto

(Warehouse)

81 Resources Road

Etobicoke ON M9P 3T1

Email: PHOL.Warehouse@oahpp.ca

Fax: 416 235-5753

Fax completed requisitions to your closest Public Health Ontario Laborat oryquotesdbs_dbs7.pdfusesText_13

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