SUPPLIES REQUEST FORM Winnipeg MB R3C 3Y1 (PLEASE FAX ONLY: Fill out & sign online

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Begin by clicking ‘Get Form’ to open the SUPPLIES REQUEST FORM in our editor.
Fill in the 'Patient Information' section clearly, including the patient's legal name, date of birth, and sex. Ensure all mandatory fields are completed for processing.
In the 'Relevant Clinical Information' section, provide details such as outbreak code and reason for the test. Select from the options provided or specify any other relevant information.
Complete the 'Specimen Information' section by indicating the specimen type and source. Be precise to avoid any delays in processing.
Review all entered information for accuracy before finalizing your form. Once satisfied, save your changes.
Finally, fax the completed form using a secure fax machine to ensure confidentiality and compliance with submission guidelines.

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