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

HOSSPCODE

MAH

WARD
D

SH AWP

TEESTCODES

asindicated

BILLCODE
E

CPRF-022

SP
PR

Version 2 12//02/2016

Authorised
A
by W.
W Wilcox


Collection Centres
ColleectionCen
ntres

Colle
ectionCentreo
openinghour
rsareavailable
Collection Centre
opening hours
are availableeat
at
http://pathology.mater.org.au/for-patients/collection-centres
http://patho
ology.mater.oorg.au/forpattients/collectioncentres

Location

Address

AlexandraH
Hills

Sh
hop38,71Cam
mbridgeDrive

0738202618

Beenleigh

Sh
hop10,145Geo
orgeStreet

0738078827

Brookwaterr

BrrookwaterVillageShoppingCeentre
Leevel1,MaterHealthCentre,2TournamentD
Drive
Su
uite1A,1stFloo
or,200OxfordSStreet

0731993250

0733263400

Cleveland

Ho
olySpiritNorthsideHospital,G
GroundFloor(n
nearDeckCaf)),
62
27RodeRoad
Sh
hop3,Bldg2,B
BaysideBusines sPark,16Weip
ppinStreet

Coorparoo

Cn
nrOldClevelandRdandFrencchSt

0733975494

Deagon

DeeagonMarketSSquare,5575BBraunStreet

0738694291

Hamilton

8HerculesStreett

0731513001

HopeIsland
d

M
MaterHealthCe
ntre,8HalcyonnWay

0756354050

Inala

11
19BiotaStreet

0733725770

Ipswich

14
4BrisbaneStreet

0738123937

KaranaDow
wns

1LangiCourt

0732012549

Kedron

Teenancy3,232G
GympieRoad

0733576517

Kenmore

Sh
hop7,TheCourrtyard,2060MooggillRoad

0733789784

Keperra

GrreatWesternSuperCentre,CnnrSamfordand
dSettlementRo
oads

0733518563

LoganCentrral

Lo
oganCentralPla
aza,3874Wem
mbleyRd

0732994343

MacleayIslaand

32
240HighCentrralRoad

0734094318

Oxley

16
69SeventeenM
MileRocksRoadd

0733754806

RussellIslan
nd

AllisonCrescent

0734092946

SouthBrisb
bane

Leevel6,MaterPrrivateHospital,,301VultureSttreet

0731637625

SouthBrisb
bane

Leevel4,MaterHospitalBrisban e,RaymondTe
errace

0731638732

Springfield

0734701055

Springwood
d

Leevel1OrionSho
oppingCentre,
Cn
nrCentenaryHwyandSpringffieldGreenbankkArterialRd
18
8DennisRoad

Springwood
d

Sh
hop2,3MurrajongRoad

0732992502

SunnybankHills

VictoriaPoiint

Sh
hop2D,Level4,SunnybankH illsShoppingto
own,
Cn
nrCalamandComptonRoads
12
23ColburnAvenue

0732728347

Yamanto

Sh
hop26B,Yaman
ntoShoppingV
Village,502510
0WarwickRoad
d

0732941735

Bulimba
Chermside

Telephone

0739020695

0731637350

0732091691

0732077028