Test Request Form [name laboratory] – Patient details Requester details: Name: Name: Address: Organization Telephone number: Address: Date of Birth: Telephone number: Gender: Male Female Sample details: Urgency: Normal Sample taken from patient: URGENT Date: (dd/mm/yyyy) Time: (hh/mm) Fasting Non-fasting Blood Urine Swab Tissue Faeces Sputum Fluids Cytology Other, namely: Relevant clinical information: Drug therapy: Last dose: Date: (dd/mm/yyyy) Time: (hh/mm) Other relevant clinical information: Examination requested: Profile test Biochemistry Hematology Microbiology Anatomical Pathology G2000 DFS CEA HIV 1 & 2 FBE (incl. ESR) Urine FEME Histology G 2000-X LFT CA 1 HbA1c FBC RPR (VDRL) Non-Gynae/FNA GT9 RFT CA 5 Hb Microscopy/Culture/Sensitivity GTI TFT CA 9 H. pylori TWDC AFB (ZN) Smear Only Site: NEO MAC PSA Uric Acid Platelets AFB Smear & Culture ES LGL AFP Free T4 ABO & Rh (D) HB3 LIP Glucose Malaria parasites Additional tests: Cervical Cytology: Pap smear Normal Post-Mono Blood Susp lesion Other: Site Cervix Endocx Post Fornix Vault Lat. Vag. Wall. Other, namely: LMP (dd/mm/yyyy) Post menopausal – HRT (hormone Replacement Other, namely: Date: Requester’s signature: (dd/mm/yyyy)
Test Request Form – [name laboratory] Patient details Requester details: Name: Name: Address: Organization Telephone number: Address: Date of Birth: Telephone number: Gender: Male Female Sample details: Urgency: Normal Sample taken from patient: URGENT Date: (dd/mm/yyyy) Time: (hh/mm) Fasting Non-fasting Blood Faeces Urine Sputum Swab Fluids Tissue Cytology Other, namely: Relevant clinical information: Drug therapy: Last dose: Date: (dd/mm/yyyy) Time: (hh/mm) Other relevant clinical information: Examination requested: Profile test Biochemistry Hematology Microbiology Anatomical Pathology G2000 G 2000-X GT9 GTI NEO ES HB3 DFS LFT RFT TFT MAC LGL LIP CEA CA 1 CA 5 CA 9 PSA AFP Glucose HIV 1 & 2 HbA1c H. pylori Uric Acid Free T4 FBE (incl. ESR) FBC Hb TWDC Platelets ABO & Rh (D) Malaria parasites Urine FEME RPR (VDRL) Microscopy/Culture/Sensitivity AFB (ZN) Smear Only AFB Smear & Culture Histology Non-Gynae/FNA Site: Additional tests: Cervical Cytology: Pap smear Normal Post-Mono Blood Susp lesion Other: Site Cervix Vault Other, namely: Endocx Lat. Vag. Wall. Post Fornix LMP (dd/mm/yyyy) Post – menopausal HRT (hormone Replacement Other, namely: Date: (dd/mm/yyyy) Requester’s signature:
Template%20Laboratory%20Request%20Form_0.docx