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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 at www.publichealthontario.ca/requisitions.
Requisitioner’s name:
Telephone no.:
Date:
Fax no.:
Authorized Signature:
Ship to (include Client name, Address and Postal code):
Name Kits Item # UoM Quantity
Chlamydia
trachomatis
& Neisseria
gonorrhoeae
NAA testing
Roche cobas
®
PCR Urine Sample kit 300316 Box of 100
Roche cobas
®
PCR Media Dual Swab
Sample kit
300317 Box of 100
DF Direct Fluorescence 390047 EA.
Enteric
Outbreak kit
2 vials: Green-Enteric Bacteriology and
White-Virology / Toxin testing
390036 EA.
FAECES
Enteric Bacteriology – Health Units Only
(Cary Blair)
390049 EA.
GL Gastric Lavage - M. tuberculosis 390043 EA.
PARA Faeces - Routine Parasitology 390033 PKG / 3
TB
TB kit Sputum Body uids and tissues
(90 ml sterile container)
390042 EA.
CD
C. dicile analysis or toxin studies
(90 ml sterile container)
390054 EA.
Virus Culture
(tissue)
Universal Transport Media (UTM) 390075 EA.
Water
Private Citizen Water - bacteriological 390040 EA.
Sterile - Water bottles - 250 ml
(Ocial Agency Use Only)
300013 EA.
PWO kit Pinworm Ova Kit 390045 EA.
BL-S
Blood, clotted
Serology - Syphilis / Virus / Other
390044 PKG / 6
BP Bordetella pertussis (Whooping cough) 390052 PKG / 2
CHL(C)
Female, Chlamydia trachomatis culture
(Universal Transport Media-UTM)
390083 PKG / 6
Male, Chlamydia trachomatis culture
(Universal Transport Media-UTM)
390084 PKG / 6
MP / CP - Resp
Mycoplasma pneumoniae /
Chlamydophila pneumoniae - Respiratory
390085 PKG / 6
F
Fungus culture kit (supercial /
dermatophyte)
390048 PKG / 6
GC Neisseria gonorrhoeae culture 390051 PKG / 6
MP
Genital Mycoplasma / Ureaplasma culture
(Universal Transport Media-UTM)
390064
PKG / 6
Prenatal Rubella, Syphilis, Hep.B, HIV 390050 PKG / 6
Virus Culture
- Herpes / STI
Swab in transport medium
(Universal Transport Media-UTM)
390081 PKG / 6
Virus -
Respiratory
/ Inuenza
Nasopharyngeal swab in transport
medium (Universal Transport Media-UTM)
390082 PKG / 6
Virus - Enteric
Virus culture/electron microscopy /
PCR & direct antigen testing
390087 PKG / 6
Description Item# UoM Quantity
Biohazard Bags - Clinical
Specimens (Self-Seal)
300008 PKG / 100
Test Requisition Bacterial
Analysis of Water
(Private Citizen - single
sample) (Form # 3743-44)
300087 PKG / 100
Test Requisition Bacterial
Analysis of Water
(Ocial Agency - multiple
sample) (Form # 4321-44)
300089 PKG / 100
General Test Requisition
(Form # 97-44) PHL
300122 PKG / 100
Test Requisition Prenatal
(Form # 1739-44)
300086 PKG / 100
Comments:
Date order received (yyyy/mm/dd):
Order lled by:
Date order shipped (yyyy/mm/dd):
F-SD-SCG-1003-009 (21/11/16)