Diagnostic Laboratory
tel: (514) 398-8289
e-mail: / Diagnostic Lab No.:
Date Received:

GENERAL REQUISITION

Investigator: / Requested by:
Bill to
Department:
or Institute: / e-mail RESULTS to:
Telephone: / e-mail RESULTS to:
PO or FOAPAL#:
BIOCHEMISTRY
Total Panel - 0.250mL serum min. (Albumin, AST, BUN, Phosphorus, Creatinine, Na, K, CI, Magnesium, Total Protein, Alk Phos, ALT, Total Billirubin, Calcium, CK, Glucose, Cholesterol)
Individual test (Check) – 0.05 mL serum min. +0.01 for each additional test
Na BUNBilirubin (Total)
K CreatinineBilirubin (Direct /
CIProtein (Total)Indirect)
Albumin AST
Glucose CalciumALT
Phosphorus GGT
Cholesterol Magnesium Alk Phos
TriglyceridesCK
HDL Amylase
Lipase
HAEMATOLOGY
CBC (complete blood count) Reticulocytes
CBC & differentialHematocrit
MICROBIOLOGY - Bacterial Culture (specify)
Oral swab Micromonitoring
Tracheal Lavage Sensitivity
Genital Other (specify)
Rectal______
PARASITOLOGY
Ectoparasites (direct) Faecal flotation
Acetate tape test
URINE ANALYSIS
Dipstick only
Dipstick & Microscopy
Biochemistry (Full Panel):Sodium, Potassium, Glucose, Urea, Creatinine, UPRO, Amylase, Calcium, Phosphorus, Magnesium
Biochemistry (Panel 1):Sodium, Potassium, Glucose, Urea, Creatinine, UPRO, Amylase
Biochemistry (Panel 2):Calcium, Phosphorus, Magnesium / SEROLOGY
Mouse
Level 1: MHV, MVM, MPV, NS1, MNV, MYP, TMEV, EDIM
Level 2: Level 1 + PVM, Reo3, LCM, Ectro
Level 3: Level 2 + MAD1, MAD2, Polyoma
Level 4: Level 3 + ECUN, CARB, Tyzzer’s, MCMV, Sendai
Mouse individual test (specify)______
Rat
Level 1:RCV, RPV, RMV, KRV, H-1, RTV, NS-1
Level 2:Level 1 + Reo3, LCM, MAD1, CARB, Hantaan, Tyzzer’s, Sendai, PVM, MYP
Rat individual test (specify)______
Non-Human Primate
B-Virus
Panel A1(B-Virus, SIV, STLV, Measles, SRV)
PCR TESTING
Biological Material
Mouse/Rat Profile 1 Rat Profile 3
Mouse Profile 2 Human Profile 4
Individual Test (pinworm, helicobacter,…)
(specify)______
COMPLETE HEALTH STATUS PROFILE
Serology (Panel 4 for mouse, Panel 2 for rat), Parasitology (ectoparasite and endoparasite by PCR), Bacteriology (by PCR), Gross observation
OTHER (specify):______

Identification of samples

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14.01.31General Requisition

LIMITATION OF PROFESSIONAL LIABILITY & WARRANTY

The Investigator agrees to limit any and all liability or claim for damages, for cost of defense, or for any expenses to be levied against McGill University and the Animal Resources Centre to a sum not to exceed $1,000 or the amount of the fee for diagnostic or technical services performed, whichever is less, when such claim arises from any error, omission, or professional negligence on the part of the Animal Resources Centre. Professional services performed, findings obtained and recommendations prepared are in accordance with generally and currently accepted consulting principles and practices in laboratory animal medicine, and regulations and guidelines for the care and use of laboratory animals. This warranty is in lieu of all other warranties either expressed or implied.