Download Test Collection Instructions

Sending Your Sample
Sample must arrive at the laboratory on a weekday. Send
sample as soon as possible after collection.
Urine HGH
Requisition
2
1
Collection Instructions
BIOHAZARD
___________
Doe
___
Jane
___________10
01___________ am
Name:
1952 03 10 / 6:00____
& Last ___________
___________
2011
of Birth: Collection:
of
& Time
Date
Date
BIORISQUE
Urine HGH
If your FedEx pack does not include a pre-printed ‘From’ or
‘Sender’ address, please complete the FedEx waybill with your
name, address, and phone number.
Styrofoam kit box
Advancing the Science of Wellness
Rocky Mountain Analytical
Before You Begin
Urine HGH Kit
Styrofoam Box
Next check off:
•
•
•
•
Urine Growth Hormone
Freeze pack
First
Place the purple-top tube containing your sample into the
plastic biohazard bag and ensure the bag is sealed. Then
place the requisition, the frozen freeze pack and the sealed
plastic bag into the styrofoam box and place box into the
FedEx clinical pack provided. Remember to seal the FedEx
pack.
Rocky Mountain Analytical®
Changing lives, one test at a time
3
Advancing the Science of Wellness
Rocky Mountain Analytical
FedEx
FedEx Priority Overnight (section 5a)
FedEx Pack (section 6)
Special Handling - NO (not dangerous) (section 7)
Payment - Bill Recipient (section 8)
Express
Next, either:
a. Return the FedEx package to your healthcare professional
for shipping, or
b. Take the FedEx package to your nearest FedEx drop off
location. No cost to you. See: www.fedex.ca for drop-off
locations, or
Return
to Health
Care Clinic
•
Read all instructions prior to collecting urine
•
Absorbent material must stay inside the bag only
•
Collection tube is for urine only
•
Set aside a clean, dry container for urine collection
•
Check contents of the kit. If anything is missing, please
contact your healthcare professional
FedEx
Express
or
FedEx
Drop Off
Location
c. Call FedEx and schedule a pick-up from your location.
1.800.463.3339
Kit Contents
Getting Your Results
Results will be sent to your health care provider
approximately seven (7) to ten (10) days after your sample
has been received by Rocky Mountain Analytical. Note that
the sample may take several days to arrive at the lab.
!"#
$$$%&%'&
#
(
)*+,,,
-+,,,.
'
John Smith ND
123 Any Avenue
Calgary, AB
'
John Fitness
3000 Long Street
Calgary AB
)
!"#$#%&
7
(
,
)*+
-+
(
* + ,- , .*%.
01
2"65*''
&:4
/
8
8
,8
.8
9 98
8
'
#8
72";<=>
Please contact your healthcare professional if you have
questions regarding your results.
Note: Rocky Mountain Analytical staff do not discuss test
results with patients.
Patient Privacy
Privacy Statement: Your healthcare professional’s stamp or signature on the requisition is our legal
authority for analyzing your sample. The personal information you provide is necessary for us to
provide a thorough analysis. This information will be stored confidentially and used only for the purpose
of analyzing your specimen. Some aggregate data may be used for research purposes. If you have
any questions regarding this or any other issue regarding our testing, please contact Rocky Mountain
Analytical. P: 403-241-4500 | [email protected] | F: 403-241-4501.
•
•
•
•
•
•
•
•
•
Requisition form
Collection instructions
1 x disposable transfer pipette
1 x 50 mL purple-top specimen tube
Biohazard bag containing an absorbent square
Freeze pack
Styrofoam kit box
Return addressed envelope
3L container (supplied by your healthcare professional)
www.rmalab.com
P: 403.241.4500 | [email protected] | F:403.241.4503
A division of LifeLabs LP
How to Prepare
IMPORTANT: COLLECT EITHER SAMPLE A or B
If you miss a collection, either overnight or during the 24-hr collection, you will need to
discard all urine and start over again.
Maintain normal fluid intake the night before collection. The average 24 hour urine
output is 2 L. Excessive water intake (> 8 glasses) may dilute sample and affect test
results.
If your total 24-hour urine volume is less than 1 litre or more than 3 litre discard sample
and re-collect, adjusting fluid intake accordingly.
A
Overnight Urine Collection (includes overnight and first morning urine)
Urine Human Growth Hormone
Accession # (Lab Only)
Requisition
Rocky Mountain AnalyticalTM
Changing lives, one test at a time
Note: Send either FIRST morning OR 24-HOUR collection - but NOT both.
NOTE: Put freeze pack into freezer overnight.
Patient Information
Date of Birth
(yyyy-mm-dd)
First AM
Date & Time
Urine Human Growth Hormone
Accession # (Lab Only)
Requisition
Rocky Mountain AnalyticalTM
Changing lives, one test at a time
Note: Send either FIRST morning OR 24-HOUR collection - but NOT both.
Gender (circle one) Address
M
F
Patient Information
Last Name
First Name
Date of Birth
(yyyy-mm-dd)
Height
Collection Information
Weight
Prov
PHN
Postal Code
Phone
(
)
Waist
cm / in (circle one)
Hip
cm / in (circle one)
Collection Date
(yyyy-mm-dd)
Collection Start Time
(circle one) am pm
24-hour
START
Collection Date
(yyyy-mm-dd)
(circle one)
24-hour
END
Collection Date
(yyyy-mm-dd)
Collection End Time
(circle one) am pm
Collection End Time
am pm
Total 24-hour
Urine Volume _________________ mL
Note: More than 3000 mL
will be rejected.
Estrogens
(e.g. Estraderm, Ogen)
Hormone Therapies
Medication Information
City/Town
cm / in (circle one)
kg / lbs (circle one)
First AM
Date & Time
Progesterone
(e.g. Prometrium)
Exercise: See Reverse
Testosterone
(e.g. Climacteron)
DHEA
(e.g. DHEA, somatropin)
Growth Hormone
Brand Used (e.g. Premarin)
Delivery (e.g. oral, transdermal)
Date & Hour of Last Use
Medication Information
cm / in (circle one)
cm / in (circle one)
Collection Start Time
(circle one) am pm
(circle one)
Collection End Time
(circle one) am pm
Collection End Time
am pm
Total 24-hour
Urine Volume _________________ mL
Note: More than 3000 mL
will be rejected.
Estrogens
(e.g. Estraderm, Ogen)
Progesterone
(e.g. Prometrium)
Exercise: See Reverse
Testosterone
(e.g. Climacteron)
DHEA
(e.g. DHEA, somatropin)
Delivery (e.g. oral, transdermal)
Date & Hour of Last Use
Length of Time of Use (e.g. 2 yrs)
Dose (in mg)
Number of Times Per Day (e.g. 2)
Days per Month Used (e.g. 25)
Other relevant medications or supplements (eg. Secretopin)
0123
Hot Flashes
0123
Allergies
0123
Mood Swings
0123
Increased acne
0123
Uterine fibroids
0123
Night Sweats
0123
Nausea
0123
Irritability
0123
Oily skin
0123
Breast swelling
0123
0123
0123
Heart Palpitations
0123
Water Retention
0123
Cold Body Temp
0123
Fatigue
0123
Drowsiness
0123
0123
Anxiety
0123
Feel ‘Burned Out’
0123
Muscle aches/stiffness
Bone loss
0123
0123
Vaginal dryness
0123
0123
Caffeine consumption
0123
Decreased Muscle Mass
0123
Breast tenderness
0123
Morning sluggishness
0123
Excess facial/body hair
0123
Fibrocystic breasts
0123
Low Blood Sugar
0123
Depression
0123
Loss of scalp hair
0123
Bleeding change
24-hour Urine Human Growth Hormone
First Morning Urine Human Growth Hormone
Clinician Name (Last, First)
(or)
0123
Add-on 24-hour Urine Human Growth Hormone
APPLY BAR CODE LABEL HERE
Clinician Signature
Billing: Bill Healthcare Professional (or) Patient Payment Attached
Clinic Name
credit card only
105 - 32 Royal Vista Drive NW, Calgary, AB T3R 0H9 | Phone: 403-241-4500 | Fax: 403-241-4501|[email protected] | www.rmalab.com
Jane Doe
First & Last Name: ______________________
1952 01 10
Date of Birth: _________________________
2011 03 10 / 6:00 am
Date & Time of Collection: _______________
40 mL
40 mL
24-hour Urine Collection
Length of Time of Use (e.g. 2 yrs)
Dose (in mg)
Number of Times Per Day (e.g. 2)
Days per Month Used (e.g. 25)
Other relevant medications or supplements (eg. Secretopin)
Hot Flashes
0123
Allergies
0123
Mood Swings
0123
Increased acne
0123
Uterine fibroids
Night Sweats
0123
Nausea
0123
Irritability
0123
Oily skin
0123
Breast swelling
Heart Palpitations
0123
Fatigue
0123
Anxiety
0123
Muscle aches/stiffness
0123
0123
Water Retention
0123
Drowsiness
0123
Feel ‘Burned Out’
0123
Bone loss
0123
Unable to cope
0123
Cold Body Temp
0123
Low Sex Drive
0123
Foggy Thinking
0123
Vaginal dryness
0123
Poor exercise tolerance
Weight Gain-Waist
0123
Headaches
0123
Memory Lapses
0123
Incontinence
0123
Caffeine consumption
Weight Gain-Hips
0123
Feel ‘Tired but Wired’
0123
Decreased Muscle Mass
0123
Breast tenderness
0123
Morning sluggishness
0123
Sleep Disturbances
0123
Tearfulness
0123
Excess facial/body hair
0123
Fibrocystic breasts
0123
Low Blood Sugar
0123
Depression
0123
Loss of scalp hair
0123
Bleeding change
24-hour Urine Human Growth Hormone
First Morning Urine Human Growth Hormone
Clinician Name (Last, First)
(or)
Add-on 24-hour Urine Human Growth Hormone
APPLY BAR CODE LABEL HERE
Clinician Signature
Billing:
Clinic Name
Bill Healthcare Professional (or) Patient Payment Attached
credit card only
105 - 32 Royal Vista Drive NW, Calgary, AB T3R 0H9 | Phone: 403-241-4500 | Fax: 403-241-4501|[email protected] | www.rmalab.com
NOTE: Put freeze pack into freezer overnight.
1. Empty Bladder. Note start time on requisition.
2. Use a clean cup and collect urine for the next 24 hours.
If you get up in the middle of the night you must collect
that urine as well.
Fill to 2L mark
3. Unfold the orange container and pour each urine
collection into it. Store in fridge.
4. Empty bladder one last time prior to end of 24-hours. (eg.
Use permanent ink ball point pens as other inks are water
soluble (e.g. roller ball ink) and may wash off containers or
smear.
__
__
__
n
e
N
_
st
oll
:
La irth f C
o
&
e
fB
st
Fir te o Tim
Da te &
Da
o
cti
_
7. Place tube into biohazard bag and store in the
refrigerator. DO NOT FREEZE
8. Send sample within 48 hours of collection. See HOW TO
SEND SAMPLES on back page.
Patient Information
Date of Birth
(yyyy-mm-dd)
Height
Collection Information
Weight
City/Town
Prov
PHN
Postal Code
Phone
(
)
cm / in (circle one)
Waist
kg / lbs (circle one)
Hip
cm / in (circle one)
cm / in (circle one)
First AM
Date & Time
Collection Date
(yyyy-mm-dd)
(circle one)
24-hour
START
Collection Date
(yyyy-mm-dd)
Collection End Time
(circle one) am pm
24-hour
END
Collection Date
(yyyy-mm-dd)
Collection Start Time
am pm
Collection End Time
(circle one) am pm
Total 24-hour
Urine Volume _________________ mL
Note: More than 3000 mL
will be rejected.
Estrogens
(e.g. Estraderm, Ogen)
Hormone Therapies
Progesterone
(e.g. Prometrium)
Exercise: See Reverse
Testosterone
(e.g. Climacteron)
DHEA
(e.g. DHEA, somatropin)
Growth Hormone
Brand Used (e.g. Premarin)
Delivery (e.g. oral, transdermal)
Date & Hour of Last Use
Length of Time of Use (e.g. 2 yrs)
Dose (in mg)
Number of Times Per Day (e.g. 2)
Days per Month Used (e.g. 25)
Other relevant medications or supplements (eg. Secretopin)
Please indicate the symptoms you are experiencing as 0 (none), 1 (mild), 2 (moderate), 3 (severe). For example if you have moderate allergies you would
indicate this by darkening the 2 next to ‘allergies’ e.g. 013 If you are not sure, please leave blank.
0123
0123
0123
0123
Hot Flashes
Night Sweats
Heart Palpitations
Water Retention
0123
0123
0123
0123
Allergies
0123
Nausea
0123
Fatigue
0123
Drowsiness
0123
Mood Swings
0123
Irritability
0123
Anxiety
0123
Feel ‘Burned Out’
0123
Increased acne
Oily skin
0123
0123
Muscle aches/stiffness
Bone loss
0123
0123
Uterine fibroids
Breast swelling
Feel ‘Pressed for Time’
Unable to cope
0123
Cold Body Temp
0123
Low Sex Drive
0123
Foggy Thinking
0123
Vaginal dryness
0123
Poor exercise tolerance
0123
Weight Gain-Waist
0123
Headaches
0123
Memory Lapses
0123
Incontinence
0123
Caffeine consumption
Breast tenderness
0123
Morning sluggishness
0123
Weight Gain-Hips
0123
Feel ‘Tired but Wired’
0123
Decreased Muscle Mass
0123
0123
Sleep Disturbances
0123
Tearfulness
0123
Excess facial/body hair
0123
Fibrocystic breasts
0123
Low Blood Sugar
0123
Depression
0123
Loss of scalp hair
0123
Bleeding change
24-hour Urine Human Growth Hormone
First Morning Urine Human Growth Hormone
(or)
Add-on 24-hour Urine Human Growth Hormone
Clinician Name (Last, First)
APPLY BAR CODE LABEL HERE
Clinician Signature
Clinic Name
Billing:
Bill Healthcare Professional (or) Patient Payment Attached
credit card only
105 - 32 Royal Vista Drive NW, Calgary, AB T3R 0H9 | Phone: 403-241-4500 | Fax: 403-241-4501|[email protected] | www.rmalab.com
40 mL
40 mL
BIORISQUE
1__9
_
__
__
e__ ___ __am_
__
D__o __ 6:__00
e__ _1__0_ _10__/_
_n_
J_a_ __0_1_ 11__03__
2_ _
_5_ : _20
__
__
Gender (circle one) Address
M
F
First Name
BIOHAZ-
e:
am
6. Using the pipette transfer 40 mL urine from the 24-hr
collection into the purple-top tube. Do not fill past 50
mL.
Accession # (Lab Only)
Requisition
Last Name
Medication Information
5. Record total volume of 24-hr urine on the requisition.
Test cannot be processed without this information.
Urine Human Growth Hormone
Rocky Mountain AnalyticalTM
Changing lives, one test at a time
Note: Send either FIRST morning OR 24-HOUR collection - but NOT both.
Symptom Information
if you start collecting at 7 AM empty bladder & add urine
to orange container just prior to 7 AM the following day).
Sample Labelling
Complete sample label with the following:
• Legal name (first and last) Important: The name on
your sample(s) and your requisition MUST match
exactly
• Date of birth (yyyy/mm/dd)
• Date and time of collection (yyyy/mm/dd)
Feel ‘Pressed for Time’
0123
0123
Order
0123
Health Professional
Symptom Information
0123
0123
Order
•
•
•
•
•
number(s). Important: The name on your sample(s)
and your requisition MUST match exactly
Date of Birth
Gender
Date and time of collection
Collection volume (24 hour collection)
All medication and supplements you are using as they
may affect test results
Please indicate the symptoms you are experiencing as 0 (none), 1 (mild), 2 (moderate), 3 (severe). For example if you have moderate allergies you would
indicate this by darkening the 2 next to ‘allergies’ e.g. 013 If you are not sure, please leave blank.
Health Professional
• Legal name (first and last), address, telephone
Feel ‘Pressed for Time’
Unable to cope
Poor exercise tolerance
Incontinence
Feel ‘Tired but Wired’
Tearfulness
0123
Memory Lapses
0123
0123
0123
0123
Headaches
Foggy Thinking
Weight Gain-Hips
Sleep Disturbances
0123
Weight Gain-Waist
Low Sex Drive
0123
0123
4. Place the tube into biohazard bag and store in fridge until
ready to send all samples. DO NOT FREEZE
B
Growth Hormone
Brand Used (e.g. Premarin)
Please indicate the symptoms you are experiencing as 0 (none), 1 (mild), 2 (moderate), 3 (severe). For example if you have moderate allergies you would
indicate this by darkening the 2 next to ‘allergies’ e.g. 013 If you are not sure, please leave blank.
Symptom Information
3. Mix and transfer 40 mL of urine to the purple-top tube. Do
not fill past 50 mL.
)
Waist
Order
Lab Requisition
PHN
Phone
(
Hip
Health Professional
2. Note the date and time of your first morning collection on
your requisition.
Prov
Postal Code
Collection Date
(yyyy-mm-dd)
Collection Date
(yyyy-mm-dd)
BIORISQUE
Important for Option B (24-Hour): you must record the total volume of urine collected
over 24 hours. The test cannot be be processed without this information.
City/Town
cm / in (circle one)
kg / lbs (circle one)
Collection Date
(yyyy-mm-dd)
24-hour
START
24-hour
END
BIOHAZARD
Important for Option A (Overnight): If you get up to urinate during the night you must
collect all that urine and add it to your first morning collection.
Complete your requisition with the following:
Gender (circle one) Address
M
F
First Name
Height
Weight
Hormone Therapies
1.IMPORTANT: Collect all urine after retiring for the evening.
If you wake in the night to urinate, have a clean cup ready
for urine collection. Add overnight urine to first morning
urine collection before transferring to purple-top tube.
Check your requisition to ensure it includes your
healthcare professional’s signature and bar code label.
If either are missing please contact your healthcare
professional before sending us your sample.
Last Name
Collection Information
Do not collect urine if:
• you have a urinary tract infection
• you are menstruating
Jane Doe
First & Last Name: ______________________
1952 01 10
Date of Birth: _________________________
2011 03 10 / 6:00 am
Date & Time of Collection: _______________