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Patient Information: Corp.: Bill To:: Doc. No: LPL/CLC/QF/2806

This document is a test requisition form containing patient information such as name, address, contact details, date of birth, referring doctor information, and specimen information including test codes, descriptions, amounts, and details. It outlines requirements for correct test codes, names, and specimen types. Sections are included for discount details, payable amounts, temperature details for transport, test requirements, and essential clinical information relevant to the patient and tests ordered. The form requires signatures from the patient and collector.

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4K views1 page

Patient Information: Corp.: Bill To:: Doc. No: LPL/CLC/QF/2806

This document is a test requisition form containing patient information such as name, address, contact details, date of birth, referring doctor information, and specimen information including test codes, descriptions, amounts, and details. It outlines requirements for correct test codes, names, and specimen types. Sections are included for discount details, payable amounts, temperature details for transport, test requirements, and essential clinical information relevant to the patient and tests ordered. The form requires signatures from the patient and collector.

Uploaded by

Tarun
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Test Requisition Form

Doc.

No : LPL/CLC/QF/2806

LPL LAB NO.

AFFIX
TEST REQUISITION FORM BAR
PATIENT INFORMATION : CORP. : BILL TO :
PATIENT’S NAME
C. C. : R.C. C. :
(Block Letters)
Name & Address: Name & Address:
Patient’s Address: ......................................................................
.....................................................................................................
UID : ..........................................................................................
Phone No. : ................................................................................
Date of Birth : .................................. Male Female REFERRING DOCTOR:
Age : ................... Years ................... Months...................Days Doctor’s Name : .....................................................................
Height : .......Ft........cm Weight : ................... Kg. Phone No. ................................................City...........................

Test Code Test Description


SPECIMEN INFORMATION
Test Amount
Hospital / CC / PUP ............................

Drawn Date : ........................................

Time Drawn : .......................................

TOTAL
Discount Percent Gross Amount Payable TEMPERATURE SENT TEMPERATURE RECD.
Less Discount (if any) Frozen (< 2º Celsius) Frozen (< 2º Celsius)
Discount Details Net Amount Payable Gel Pack (2-8º Celsius) Gel Pack (2-8º Celsius)
Less Amount Paid
Balance Due Temp (18º - 22º Celsius) Temp (18º - 22º Celsius)
FOR REPEAT / FOLLOW – UP PATIENTS
TEST REQUIREMENTS : Please refer to the LPL Reference
Guide for correct test code / Name / specimen type Old LPL Lab No. .....................................................................
SPECIMEN TYPE ESSENTIAL CLINICAL INFORMATION
Qty. CSF Qty. (Please fill in whatever is relevant)
Serum
Tissue-Small/Medium* 1) Provisional diagnosis : .......................................
Plasma EDTA/FL/ CIT/ACD
Tissue-Large* 2) H/o Medication : Yes / No
FN Aspirate
W.Blood ACD Parafin Block* 3) If yes, Name: ........................................................
W.Blood EDTA Smear 4) Status of Medication : Ongoing / Terminated
W. Blood Fluoride Slide (H & E)*
5) If ongoing, Duration: ............................................
W. Blood Heparin Urine 1st Morn. /
Random Urine / 6) If terminated, When: ............................................
W. Blood Sodium Citrate
24 hrs Urine 7) Fasting Period ......................................................
Pus
BAL 8) 24 Hour Urine Volume .........................................
Fluid
Sputum Stool 9) For Histopathlogy / IHC, Attach Detailed History
Filter Paper Swab* 10) LMP (where applicable) .....................................
Bone Marrow Others* 11) Diabetes Status: Yes / No
*Mention Type / Site of Collection 12) Gestation Single / Twin
TICK SAMPLE WHICH EVER IS APPLICABLE. 13) Attach other relevant information .......................

Signature / Thumb impression of patient

Date :
* Signature of CC / PUP / Hospital
Date :

1.) It is mandatory to provide all the requested information to enable accurate and timely reporting.
* NOTE :
2.) Consent is hereby given to use my sample for Quality Assurance & Research purposes if needed.

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