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 First and last names : BD (yyyy/mm. [...] ** 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 / #1 Page F-11-117 ang 2021/11/01 2022/09/22 2 de 2 mailto:ctqlab@inspq.qc.ca Address: Requesting physician name: Phone: Collection date yyyymmdd: First and last names: RAMQ: File: Clients reference: OTHER SPECIFYMetal.