Provincial Laboratory Test Requisition Forms

• Autologous Sperm Cryopreservation Requisition Form
• Breast Cancer Biomarker Requisition Form
• Cancer Cytogenetics Requisition
• Constitutional Cytogenetics Requisition
• Cytogenetics Requisition for Amniocentesis
• Cytology Laboratory Non Gyn Specimen Requisition
• Endocrinology Requisition Form (Outpatients) 
• Fecal Immunochemical Test (FIT test) Requisition Form
• Fertility Services Specimen Collection Requisition Form
• Flow Cytometry Requisition-Leukemia Lymphoma Investigation
• Harmony Prenatal Test Requisition
• Laboratory Test Special Authorization (LTSA) Form
• Maternal Serum Screen Requisition Form
• Medical Genetics Laboratory Test Requisition for Solid Tumor
• Microbiology Referral
• Molecular Genetics Laboratory Requisition Form
• Outpatient Laboratory Requisition Form
• Outpatient Special Hematology Requisition Form 
• Pap Smear Requisition Form
• Pathology Specimen Requisition
• Placental Pathology Requisition
• Public Health and Microbiology Specimen Collection Requisition
• Semen Analysis Requisition
• Special Hematology Adult Bone Marrow Flow Cytometry and Genetics Requisition

Pediatrician Requests for Microarray and Fragile X/XE Genetics Tests

Ordering restrictions have been lifted to allow pediatricians only to request Fragile X A.FMR1 and Fragile X E. FMR2 when investigating children with global developmental delay and intellectual disability.

The proper requisitions must be fully completed and submitted to the Newfoundland and Labrador Health Services Genetics Laboratory. Test requests and specimens will be accepted only from pediatricians. Specimen collection instructions on the requisitions must be strictly adhered to.

Link to Genomic SNP Microarray (with billing) from Toronto SickKids Laboratory:  SNP Microarray Requisition

Link to Requisition for Fragile X Orders : Requisition for Fragile X Orders (NLHS)

PLF Test Addition and Changes Form

• Application Form for Additions and Modifications to the Provincial Laboratory Formulary

The Provincial Laboratory Formulary (PLF) contains a listing of tests that are approved for ordering in the province of Newfoundland and Labrador. New candidate tests for the PLF are reviewed by the Provincial Laboratory Formulary Advisory Council (PLFAC) to determine if the following criteria are met:

• The clinical indications for testing are clear.
• The test result is required for patient management decisions.
• The test fills a unique clinical niche not filled by more effective investigations.
• The test provides the most cost-effective option available.
• The test is available from an accredited clinical laboratory and has been validated for clinical use.

Tests meeting all of these criteria are usually approved. If one or more of the above criteria are not met, a more intensive review is conducted to determine whether or not the test should be listed in the PLF.

Changing and/or Adding Tests to the PLF

Changing an existing PLF test entry or adding a new test to the PLF requires completion of the Application Form for Additions and Modifications to the Provincial Laboratory Formulary. Completed application forms are forwarded to the PLFAC for review. Please consult the Procedures and Policy Page for further information.

Requesting Authorization for a Tier 2 or Tier 3 Test

The Laboratory Test Special Authorization Form is used to gain approval for Tier 2 and Tier 3 tests. This form must be presented with the test requisition at the local laboratory specimen collection area. Please consult the Procedure for Referred Out Tests for other details on the use of this form.

Personal information captured on the Application Form for Additions and Modifications to the Provincial Laboratory Formulary is collected for the purpose of evaluating requests for changes to the Provincial Laboratory Formulary. This information is collected under the authority of section 61(c) of the Access to Information and Protection of Privacy Act, 2016. If you have any questions about the collection, use and disclosure of your information, please contact the Department of Health and Community Services at (709) 729–4984 or healthinfo@gov.nl.ca.