Dr. Brendan Byrne, MDCM 05744: Yellow Highlighted Fields Must Be Completed
Dr. Brendan Byrne, MDCM 05744: Yellow Highlighted Fields Must Be Completed
Dr. Brendan Byrne, MDCM 05744: Yellow Highlighted Fields Must Be Completed
9138586456
LAST NAME OF PATIENT FIRST NAME OF PATIENT If this is a STAT order please provide contact telephone number:
Senn Jonathan
DOB SEX Copy to PRACTITIONER/MSP Practitioner Number:
YYYY MM DD
1992-09-25 M F Pregnant? YES NO Fasting? h pc Turgeon, Susie Annice 08039
PRIMARY CONTACT NUMBER OF PATIENT SECONDARY CONTACT NUMBER OF PATIENT OTHER CONTACT NUMBER OF PATIENT Copy to PRACTITIONER/MSP Practitioner Number:
+17787072798
ADDRESS OF PATIENT CITY/TOWN PROVINCE POSTAL CODE
Diabetes mellitus
HEMATOLOGY URINE TESTS CHEMISTRY
Hematology profile On Anticoagulant? Yes No Glucose – fasting (see reverse for patient instructions)
Macroscopic → microscopic if dipstick positive
INR Specify: Glucose – random
Macroscopic → urine culture if pyuria or nitrite present
Ferritin (query iron deficiency) GTT – gestational diabetes screen (50 g load, 1 hour post-load)
Macroscopic (dipstick) Microscopic * GTT – gestational diabetes confirmation (75 g load, fasting, 1 hour
HFE - Hemochromatosis (check ONE box only)
* Clinical information for microscopic required: & 2 hour test)
Confirm diagnosis (ferritin first, + TS, + DNA testing)
GTT – non-gestational diabetes
Sibling/parent is C282Y/C282Y homozygote (DNA testing)
Hemoglobin A1c
MICROBIOLOGY – LABEL ALL SPECIMENS WITH PATIENT’S FIRST & LAST NAME, DOB, PHN & SITE Albumin/creatinine ratio (ACR) - Urine