Required Demographic and Test Information

Field

Instructions

Personal Health Number (PHN)

Print the patient’s PHN (or indicate an alternate billing method using the tick boxes provided)

Patient Name

Print the patient’s LAST name followed by the FIRST name (and middle initial if possible).

Date of Birth & Gender

Many tests use age and/or gender to provide the appropriate reference ranges on the report.

Patient Phone Number

Patient phone number is important to both the physician and the laboratory in the event that the patient must be contacted regarding unexpected critical laboratory findings.

Ordering Physician Name, Address and MSP Practitioner Number

MSP requires that all requisitions include the ordering physician information and billing number. A physician stamp or label is preferred. This is especially important for physicians that have multiple office locations.

Please complete the Copy to Physician and Locum for: sections as appropriate for this patient visit.

STAT REQUEST: If you request a test result STAT, you must include an after-hours phone number to ensure that we can contact you directly when the testing has been completed.

Physician Signature/Date

The ordering physician’s signature and date are required by MSC. This field is located at the bottom of the requisition.

Diagnosis and indications for guideline protocol and special tests

Where protocols and ordering guidelines exist, laboratory test orders may only be requested based on certain diagnoses or clinical histories. Should this be the case, the required diagnosis or condition must be written on the requisition in order for the laboratory to proceed with the testing.

BC Biomedical has color-coded the test tick boxes (light-blue) to signal that the provincial guidelines/protocols should be consulted.

See http://www.bcguidelines.ca/gpac/index.html for additional information.

 

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