PaLM Request for Service New 2013

Request for Services - Clinical Laboratories

We welcome the opportunity to serve you. Please provide us with the details of your service request, and we will contact you with a quote and directions for specimen handling should you be ready to proceed. Should you prefer to discuss your service needs, please contact us directly at 1-519-685-8500 x56495, or lab@lhsc.on.ca

Financial Quote Only
Financial Quote and Proceed with Service
Client:(Requesting Hospital/Physician/Researcher)Contact Name:
A value is required. A value is required.
Email Address:Address:
A value is required. A value is required.
Phone Number:
A value is required.
Service Request:
Tests Required:

Additional information:

Serum
Plasma
Whole Blood
Fluid:
Urine
Stool
Other
Species:
Approximate Volume (# of patients):
Start Date:
Month: Day:
For London-based research (only):






Sample Handling Request
Site: (Check all that apply)
UH VH SJHC

- if checked please indicate # of tubes/patient


I have read and agree with the Standard Terms and Conditions: Please make a selection.


Schulich School of Medicine and Dentistry London Health Sciences CentreSt. Joseph's Health Care LondonWestern University