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Test Request Form - (Name Laboratory) : Patient Details Requester Details

This document is a test request form for a laboratory. It collects information about the patient such as name, address, date of birth and gender. It also collects sample details including the type of sample, date and time taken. Additional clinical information and examination requested are listed. The requester's name, organization, address and contact details are also provided. The form is used to request various medical tests and collect relevant information to process the sample and tests.

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Misty Collings
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5K views1 page

Test Request Form - (Name Laboratory) : Patient Details Requester Details

This document is a test request form for a laboratory. It collects information about the patient such as name, address, date of birth and gender. It also collects sample details including the type of sample, date and time taken. Additional clinical information and examination requested are listed. The requester's name, organization, address and contact details are also provided. The form is used to request various medical tests and collect relevant information to process the sample and tests.

Uploaded by

Misty Collings
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Received: ___/___/______

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  HBsAg  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: (dd/mm/yyyy) Requester’s signature:

Adapt this form to your own situation.

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