Requisition for Specimen Containers and Supplies
Physician's OHIP Billing Number:
Your Name
Clinic Phone Number:
Clinic Fax Number:
Date
/
Month
/
Day
Year
Date
Signature
Name of Clinic
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Chlamydia trachomatis & Neisseria gonorrhoeae NAA testing | Roche cobas PCR Urine Sample kit/ 300316 - Box of 100
Chlamydia trachomatis & Neisseria gonorrhoeae NAA testing | Roche cobas PCR Media Dual Swab Sample kit/ 300317 - Box of 100
Direct Fluorescence/ 390047 - Eaches
Enteric Outbreak kit/ 2 vials: Green-Enteric Bacteriology and White-Virology / Toxin testing / 390036 - Eaches
Enteric Bacteriology – Health Units Only (Cary Blair) / 390049 - Eaches
Biohazard Bags - Clinical Specimens (Self-Seal) - PKG / 100
Test Requisition Bacterial Analysis of Water (Private Citizen) - PKG / 100
Test Requisition Bacterial Analysis of Water (Official Agency) - PKG / 100
Gastric Lavage - M. tuberculosis / 390043 - Eaches
Faeces - Routine Parasitology / 390033- PKG / 3
TB kit Sputum Body fluids and tissues (90ml sterile container) 390042 - Eaches
C. difficile analysis or toxin studies (90ml sterile container) 390054 - Eaches
Virus culture (tissue) - Universal Transport Media (UTM) 390075 - Eaches
Pinworm Ova Kit - 390045 - Eaches
Blood, clotted Serology - Syphilis / Virus / Other - Pkg/6
Bordetella pertussis (Whopping cough) 390052 - Pkg/2
Female, Chlamydia trachomatis culture (UTM) 390083 - Pkg/6
Male, Chlamydia trachomatis culture (UTM) 390084 - Pkg/6
Mycoplasma pneumoniae / Chlamydophila pneumoniae - Respiratory 390085 - Pkg/6
Fungus culture kit (superficial / dermatophyte) - 390048 - Pkg/6
Neisseria gonorrhoeae culture - 390051 - Pkg/6
Genital mycoplasma /ureaplasma culture (UTM) 390064 Pkg/6
Rubella, syphilis, hep b, HIV - 390050 - Pkg/6
Swab in transport medium (UTM) - 390081 - Pkg/6
Nasopharyngeal swab (UTM) - 390082 - Pkg/6
Virus culture/electron microscopy / PCR & direct antigen testing
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