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Standardized Provincial Anatomical Pathology Request Form

October 10 , 2017

Key Message:

A standardized Anatomical Pathology request form is being implemented provincially to replace the variety of versions previously in use across the province.

Edmonton Zone’s current form: Cytopathology/Tissue Pathology combines cytology and tissue pathology samples on the same form.

The new provincial Anatomical Pathology Requisition is to be used only for tissue samples.

A new Edmonton Zone form: Nongynecologic Cytopathology Requisition has been created to be used for nongynecologic cytology samples.

Note: Please transition to the new forms by January 1, 2018. After this time the Cytopathology/Tissue Pathology request form will no longer be accepted.

Why this is important:

  • The new Anatomical Pathology requisition is expected to assist with decreasing delays and quality concerns that occur as a result of incomplete / incorrect information on the current Anatomical pathology / Histology test requrest.
  • A standardized provincial AP request form will mitigate the risk of sample indentification errors.

Action Required the new forms are now available as follows:

 New Form  Used For Form Number   Web link  Replacing
Anatomical Pathology Requisition tissue samples 19027(Rev2017-05) Web Link


Cytopathology / Tissue Requisition CH-0023 

Nongynecologic Cytopathology Requisition Nongynecologic cytology samples  208984(2017-09) Web Link

Note:  DynaLIFE forms will not be re;laced.  Continue using current DynaLIFE forms.

Print Access:  AHS facilities can access the print version through their usual ordering processes:

      • Data CM (For AHS Staff not registered as users - self register here for account set-up.  If you have questions or require further assistance with the online order system contact the AHS Help Desk @ DATA CM at 403.207.6631 or via email)

For any non-AHS agencies:  If you are not registered as a user please email to request the online set-up form.  A credit card will be required for each online purchase.

For implementation of the form in physician clinic EMR systems:  please have your vendor email and the Forms Program will provide assistance.

If you need more information or assistance with getting access to the form, email.

  • Physician/Requestor(s) MUST complete tfollowing sections on the FRONT page, following the Acceptance of Laboratory Samples and Test Requests provincial policy:
      • Patient Demographics
      • Requestor(s) Information
      • Collection information
      • Clinical Information, including:
        • Current Problem(s) / Differential Diagnosis
        • Relevant Family / Past Medical History
        • Additional Information
      • Sample / Tissue(s) description
  • Review the Requisition Requirements job aid
  • ONLY Laboratory staff will complete all applicable sections on the BACK of the form

Additional Information:

The AHS Test Directory for Edmonton Zone anatomical pathology and cytopathy samples has been updated

Access the AHS website for infomation on the following tests:

Anatomical Pathology Cytopathology

Routine Surgical Specimens
Intraoperative Consult (Frozen Section)
Cardiac Biopsy - Native
Cardiac Biopsy - Transplant
Muscle Biopsy
Nerve Biopsy
Electron Microscopy
Kidney Biopsy-Native
Kidney Biopsy-Transplant
Kidney Biopsy-Baseline/Donor

Aspirated cyst fluid
Brochial Brushings
Bronchioalveolar lavage BAL
Cerebral Spinal Fluid CSF
Cytodiagnostic Urinalysis
Fine Needle Aspirate Clinic
Fine Needle Aspirate FNA
Serous Fluids
Urine for Cytology


Inquiries and feedback may be directed to:

Site Anatomical P)athology Tech Ils

Jenny Zadunayski- EZ Anatomical Pathology Quality Assurance Tech II email or 780.407.8481



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