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This

s form is NOT
T for use withh the followin
ng occupation
ns:


Plumber
Wo
orker in Child Care Centre

PATHO
OLOGY REQ
QUEST FORM
M - NON ME
EDICARE BIL
LLING
TELEPHONE: 07 31633 8500

APA 000526

EMPLO
OYEE DETAILS
S
Surnamee:

DOB:

Given Naame:

Sex:

Addresss:

Mater Employee
Numbe
er

Suburb:

Male

Female

Teleph
hone
(Home
e/Mobile)

POSTCODE:

REQUE
ESTING DOCTTOR

COPY
Y TO:
DETAILS
S:

DOCTOR
R CODE:

SHAWU

DETAILS
S:

Occupatio
onal Health Team
Staff Health and Wellbeing Unit
Mater Health Services
South Brisbbane QLD 4101

DATE OF
F
REQUES
ST:

EMPL
LOYEE PRE--COMMENC
CEMENT TES
STS
Required

Description

Test Code

Hepaatitis B Immune S
Status

HBsAb
b

Meassles IgG Immune Status

MeasG
G

Mum
mps IgG Immune Status

MumpG
G

Rubeella IgG Immune Status

RubG

Varicellla Zoster Immunne Status

VZ

Cost
$$16.67 each
3 tests = $50
5 teests = $83.35

* If individual check boxes aboove are left uncheecked, all the tessts will be perform
med.

PAYRO
OLL DEDUCTIO
ON AUTHORIT
TY

I authorise Matter Pathology to undertake a payroll deduction of $ _____
_______
(inseert total)

over

___________ pa
ay cycles.
(insert 1 or 2)

______________
___________________________________________

All Employee
es
MU
UST comple
ete
and SIGN
Payrroll Deducttion
Authority
at
a or before
e
collection of sam
mples.

(Employee Siggnature)

Mater Hea
alth Services
s payroll deduction onl y applies when tests arre performeed by Mater Pathology.
Mater
M
Health Services is
s not respon
nsible for pa
ayment of te
ests perform
med by differrent patholo
ogy providerrs.
COLLE
ECTION DETAIILS
Date
Collected

/

Sample TTypes
And Nu mber

/

Time
Collected

Collect Code or
o
Stamp:

I certiffy that I have collected the accompanying sample from the above
patiennt whose identity was confirmed by enquiry and/or examination of
their name
n
band, and that I havve labelled the sample im
mmediately
following collection.

am
m / pm

Fasting Status:

Fasting

Non
n Fasting

nature:
Sign

CSR EPISODE
E
USE O
ONLY
 

HOSSP CODE 
 

 

 MAH 

WARD

 

 

SH AWP 

TEEST CODES 

as indicated 

BILLCODE

 

CPRF-022

SP
PR 

 

Version 2 12//02/2016

Authorised
A
by W.
W Wilcox

org. 2  Tournament D Drive Su uite 1A..oorg. G Ground Floor (n near Deck Café)). 38‐74 Wem mbley Rd 07 3299 4343 Macleay Islaand  32 2‐40 High Centrral Road 07 3409 4318 Oxley  16 69 Seventeen M Mile Rocks Roadd 07 3375 4806 Russell Islan nd  Allison Crescent 07 3409 2946 South Brisb bane   Leevel 6. Bldg 2. 232 G Gympie Road 07 3357 6517 Kenmore  Sh hop 7.   62 27 Rode Road Sh hop 3.mater. The Courrtyard. 502‐510 0 Warwick Road d 07 3294 1735 Bulimba Chermside    Telephone 07 3902 0695 07 3163 7350 07 3209 1691 07 3207 7028   . 200 Oxford SStreet 07 3199 3250 07 3326 3400 Cleveland Ho oly Spirit Northside Hospital.  Collection Centres Colleection Cen ntres Colle ection Centre o opening hour rs are available Collection Centre opening hours are availablee at  at http://pathology. Cnnr Samford and d Settlement Ro oads 07 3351 8563 Logan Centrral  Lo ogan Central Pla aza. 1st Floo or. B Bayside Busines s Park. 301 Vulture Sttreet 07 3163 7625 South Brisb bane  Leevel 4. Mater Prrivate Hospital. 16 Weip ppin Street Coorparoo Cn nr Old Cleveland Rd and Frencch St 07 3397 5494 Deagon Deeagon Market SSquare. Yaman nto Shopping V Village. Level 4. 145 Geo orge Street 07 3807 8827 Brookwaterr  Brrookwater Village Shopping Ceentre  Leevel 1.  Sunnybank H ills Shoppingto own.   Cn nr Calam and Compton Roads 12 23 Colburn Avenue  07 3272 8347 Yamanto  Sh hop 26B. 3 Murrajong Road  07 3299 2502 Sunnybank Hills    Victoria Poiint  Sh hop 2D. 2060 Mooggill Road 07 3378 9784 Keperra  Grreat Western Super Centre. 71 Cam mbridge Drive  07 3820 2618 Beenleigh Sh hop 10.au/for‐pattients/collection‐centres                                                                                                                                                                            Location  Address  Alexandra H Hills Sh hop 38. 8 Halcyonn Way 07 5635 4050 Inala 11 19 Biota Street 07 3372 5770 Ipswich 14 4 Brisbane Street 07 3812 3937 Karana Dow wns  1 Langi Court  07 3201 2549 Kedron  Teenancy 3. Mater Hospital Brisban e. Raymond Te errace  07 3163 8732 Springfield  07 3470 1055 Springwood d  Leevel 1 Orion Sho opping Centre.mater. Mater Health Centre. 55‐75 BBraun Street 07 3869 4291 Hamilton  8 Hercules Streett  07 3151 3001 Hope Island d M Mater Health Ce ntre.au/for-patients/collection-centres http://patho ology.    Cn nr Centenary Hwy and Springffield Greenbankk Arterial Rd 18 8 Dennis Road  Springwood d  Sh hop 2.