REQUEST FORM

BOOK A TEST

A request form must accompany every sample submitted to the laboratory. The request form must contain all our required information in order to have the specimen processed. The essential elements of the request form are:

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Patient's First & Last Name

First

Last

Patient's Hospital Number

Patient's Date of Birth

Age

Sex

Male
Female

Requesting Physician's First and Last Name

First

Last

Requesting Physician's Phone Number

Date / Time of Collection

Date

Time

Requesting Requesting

Source of Specimen

Provisional Diagnosis

Specify antibiotic therapy if patient is or recently was on any antibiotic

Indicate The Test(s) Requested

Clinical Chemistry – Renal/Bone/Electrolyte Tests