MOLECULAR MICROBIOLOGY. Referred-in VIRAL Requisition.
MICROBIOLOGY LABORATORY. Atrium, Room 3676. Tel: (416) 813-7200. 555
University Ave.
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Patient Last Name: First Name: Birth date :
(YYYY-MM-DD)
MOLECULAR MICROBIOLOGY
Gender:
Male
Female
Referred-in VIRAL Requisition For Canada Only
MICROBIOLOGY LABORATORY Atrium, Room 3676
Tel: (416) 813-7200
Provincial Health Card #: Version:
555 University Ave
Fax: (416) 813-6599
Issuing Province:
Toronto ON, M5G 1X8, Canada
IF NOT SICKKIDS PATIENT SEND REPORT TO: Referring Physician Full Name:
Mailing Address:
(Last Name, First Name) Referring Laboratory: Telephone Number: Fax Number:
Referring Lab Accession #:
SHIPPING INSTRUCTIONS: All specimens that DO NOT MEET the transport requirements will be REJECTED. STOOL • All STOOL specimens MUST be shipped FROZEN ON DRY ICE. ALL OTHER SPECIMENS • All specimens MUST be shipped ON DRY ICE. • Exception: Specimens that will arrive at SickKids within 24 hours from the time of collection can be shipped ON ICE PACKS.
TEST REQUESTED Please indicate below test(s) required. * Consult a Microbiologist for testing outside the Testing Schedule. *Page Microbiologist on-call through locating 416-813-1500 PRIOR TO SENDING SPECIMENS Specimen Volume: • CSF - 200-300ul per 1 test, for multiple tests please ensure adequate sample volume is submitted. • Serum or Plasma - 0.5mL minimum for 1 test, >1mL recommended for multiple tests. • Stool - Cary-Blair transport medium or in sterile container, NOT in container with preservative. • Whole Blood (EDTA) - 1mL minimum for 1 test, 3-5mL recommended for multiple tests.
DPLM Form #: OPL1000RMB-Ext/07, 2013-10-15
Page 1 of 2
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Patient Last Name: First Name: Birth date :
(YYYY-MM-DD)
MOLECULAR MICROBIOLOGY Referred-in VIRAL Requisition
Gender:
Male
Female
Referring Lab Accession #:
MICROBIOLOGY LABORATORY Atrium, Room 3676
Tel: (416) 813-7200
555 University Ave
Fax: (416) 813-6599
Toronto ON M5G 1X8 Canada
SPECIMEN TYPE
SPECIMEN COLLECTION INFORMATION: DATE (yyyy-mm-dd)
TIME (hhmm)
RELEVANT DIAGNOSIS
TESTS
▲ RECOMMENDED SPECIMENS ● TESTING SCHEDULE
Adenovirus Qualitative PCR
▲Plasma • Urine • Lower respiratory specimens ● 2x per week
Adenovirus Quantitative PCR
▲Plasma ● 2x per week
BK virus Qualitative PCR
▲Plasma ● Weekly (at least)
BK virus Quantitative PCR
▲Plasma ● 2x per week
JC Virus Qualitative PCR
▲CSF • Plasma • Tissue ● Weekly (at least)
CMV Qualitative PCR
▲Urine • CSF in suspected congenital CMV ● 2x per week
CMV Quantitative PCR
▲Whole Blood (EDTA) ● Weekly (at least)
Enterovirus / Parechovirus RT-PCR
▲CSF ● 2x per week
EBV - Quantitative PCR
▲Whole Blood (EDTA) ● Weekly (at least)
Gastrointestinal Pathogen Multiplex PCR
VIRUSES: Adenovirus 40/41, Rotavirus, Norovirus
BACTERIA: Salmonella spp., Shigella spp., Yersinia enterocolitica, Campylobacter jejuni/coli/lari, Clostridium difficle toxin A/B, Enterotoxigenic E.coli (ETEC), E.coli 0157, Shiga-toxin producing E.coli (STEC or EHEC), Vibrio cholerae
▲Stool • Ileostomy Fluid ● 4x per week
PARASITES: Giardia lamblia, Entamoeba histolytica, Cryptosporidium
HSV-1, HSV-2, VZV PCR
▲CSF • Other Sterile Body Fluids • Lesion scraping • Whole Blood (EDTA) • Other ● Daily on CSF/SBF specimens received by 8:30am ● Next day for Lesions received by 1:00pm
CMV, EBV, HHV-6, PCR Add HHV-7 PCR
▲Whole Blood (EDTA) • Tissue • Other ● Daily on specimens received by 10:00am
Herpes virus 8 PCR (HHV-8)
▲Tissue • Lesion scraping ● Dictated by demand
Parvovirus B19 PCR
▲Plasma • Serum ● 2x per week
Respiratory Virus Multiplex PCR
▲Lower respiratory specimens • Nasopharyngeal Swab ● Weekly (at least)
Influenza A virus subtyping
▲Lower respiratory specimens • Nasopharyngeal Swab
West Nile virus and other mosquito borne Flaviviruses
▲Plasma • Serum • CSF ● Dictated by demand (May to November)
(Influenza A/B, RSV A/B, Adenovirus, Human metapneumovirus, Coronavirus, Parainfluenza virus 1/2/3/4, Rhinovirus A/B/C, Enterovirus, Bocavirus)
(Influenza A confirmation, seasonal H1N1, pandemic H1N1 2009, seasonal H3N2, ● Weekly (at least) avian H5N1) Includes Dengue, Japanese Encephalitis, St. Louis Encephalitis
DPLM Form #: OPL1000RMB-Ext/07, 2013-10-15
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