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 kit Sputum Body uids and tissues

(90 ml sterile container)

390042 EA.

C. dicile 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

(Ocial 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

Fungus culture kit (supercial /

dermatophyte)

390048 PKG / 6

GC Neisseria gonorrhoeae culture 390051 PKG / 6

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

/ Inuenza

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

(Ocial 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)

Hamilton 250 Fennell Avenue West

Box 2100

Hamilton ON L8N 3R5

Tel.: 905 385-5379

Fax: 905 385-0083

Toll free: 1-866-282-7376

Kingston 181 Barrie Street

Box 240

Kingston ON K7L 4V8

Tel.: 613 548-6630

Fax: 613 547-1185

Toll free: 1-855-546-4745

London Unit 102,

1200 Commissioners Rd. East,

London, ON N5Z 4R3

Tel.: 519 455-9310

Fax: 519 455-3363

Toll free: 1-877-204-2666

Orillia 750 Memorial Avenue

Box 600

Orillia ON L3V 6K5

Tel.: 705 325-7449

Fax: 705 329-6001

Toll free: 1-877-611-6998

Ottawa 2380 St. Laurent Boulevard

Ottawa ON K1G 6C4

Tel.: 613 736-6800

Fax: 613 736-6820

Peterborough 99 Hospital Drive

Box 265

Peterborough ON K9J 6Y8

Tel.: 705 743-6811

Fax: 705 745-1257

Sault Ste. Marie 160 McDougald Street

Sault Ste. Marie ON P6A 3A8

Tel.: 705 254-7132

Fax: 705 945-6873

Toll free: 1-800-263-0409

Sudbury 1300 Paris Street

Suite 2

Sudbury ON P3E 6H3

Tel.: 705 564-6917

Fax: 705 564-6918

Toll free: 1-888-564-6917

Thunder Bay 336 South Syndicate Avenue

Thunder Bay ON P7E 1E3

Tel.: 807 622-6449

Fax: 807 622-5423

Timmins 67 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 (21/11/16)

www.publichealthontario.ca

Customer

Service Centre

General inquiries

Email: [email protected]

Tel.: 416 235-6556

Toll-free: 1-877-604-4567

Public Health Laboratories

Toronto

(Warehouse)

81 Resources Road

Etobicoke ON M9P 3T1

Email: PHOL.W[email protected]

Fax: 416 235-5753

Fax completed requisitions to your closest Public Health Ontario Laboratory