ANALYSIS REQUEST FORM METALS AND TRACE ELEMENTS

945, avenue Wolfe, Québec (QC) G1V 5B3 Téléphone : (418) 650-5115 poste 5100 Télécopieur : (418) 654-2754 Courriel : ctqlab@inspq.qc.ca ● www.inspq.qc.ca ANALYSIS REQUEST FORM METALS AND TRACE ELEMENTS CLIENT Hospital center / Customer: Address: Postal Code: Requesting physician name: Practice licence: Phone: Fax: Collection date (yyyy/mm/dd): Time: PATIENT Last and first names: BD (yyyy/mm/dd): R. [...] ** A result > 60 nmol/L triggers a reflex test for methylmercury, unless this analysis was performed within the last 12 months. [...] Additional information Section reserved for CTQ laboratory Sample received at: ☐ RT ☐ 4°C ☐ Frozen Formulaire # Approuvé par Ciprian-Mihai Cirtiu Date de rédaction Date de révision / #2 Page F-11-117 ang 2021/11/01 2024/04/04 2 de 2 mailto:ctqlab@inspq.qc.ca If full profile checked all highlighted analytes will be analyzedAluminum Al: If full profile checked all highlighted analytes will be analyz.