Pathology and Laboratory Medicine
Request for Services - Pathology
This form is for technical /test requests, contracts or animal research. For requests related to clinical research at LHSC see
Tissue Resources
.
Please fill in the Request for Service form below. For any questions, please call 519-685-8500, ext. 56495 or email:
lab@lhsc.on.ca
Financial
Quote Only :
Yes
No
Clinical:
Research:
Section A
Date Submitted:
Requesting Hospital/Physician/Researcher:
Contact Name:
Email Address:
Address:
Billing Address (If different from above):
Phone Number:
Existing Contract with PaLM:
Yes
No
Research Cric Number or LHR number: (if no Grant No. given, researcher will be billed directly):
Section B
Specimen Description:
Quantity of Specimens::
Species:
Human
Non Human
Laboratory:
Autopsy
Biochemical Genetics
Cytogenetics
Cytopathology / Reese Lab
Electron Microscopy
Histology
Immunopathology / Neuropathology
Molecular Diagnostics
Unknown
Laboratory Test Information Guide (complete menu)
Testing Required:
[List all testing required for each specimen]
Testing Frequency:
One-Time
Daily
Weekly
Bi-Weekly
Monthly
Yearly
As required
If other than one time, approximate number of tests per frequency:
Consultation Required:
Yes
No
Turn Around Time Required:
Special Handling Required:
Comments/Special Requests:
I have read and agree with the
Standard Terms and Conditions
:
Please make a selection.
(failure to agree to standard terms and conditions will prevent form from being submitted
)
