Department of Health

Eastern Visayas Center for Health Development

Eastern Visayas Regional Medical Center
Magsaysay Blvd, Downtown, Tacloban City, Leyte

EASTERN VISAYAS REGIONAL COVID-19 TESTING CENTER

LABORATORY TEST REQUEST FORM

SUBMITTER INFORMATION
NAME OF SUBMITTING HOSPITAL, LABORATORY, or OTHER
FACILITY*
Physician
Address
Phone number
Case definition: [ ] Suspected case [ ] Probable case

PATIENT INFORMATION
First name Last name
Patient ID number Date of Birth Age
(MM/DD/YYYY)

Phone number Sex [ ] Male [ ] Female

Address

SPECIMEN INFORMATION
Type [ ] Nasopharyngeal swab [ ] Oropharyngeal swab [ ] Bronchoalveolar lavage
[ ] Nasopharyngeal and oropharyngeal swab [ ] Endotracheal aspirate [ ] Sputum
[ ] Nasopharyngeal aspirate [ ] Nasal wash [ ] Lung tissue [ ] Serum [ ] Urine
[ ] Whole blood [ ] Stool [ ] Other
All specimens collected should be regarded as potentially infectious and you must contact the reference
laboratory before sending samples.
All samples must be set in accordance with category B transport requirements

Please tick if your clinical sample is post mortem [ ]

Date of collection Time of Collection
(MM/DD/YYYY) (Hour:Minute)

Priority status

CLINICAL DETAILS
Date of symptom onset
(MM/DD/YYYY)

Has the patient had a recent history of travelling [ ] Yes Location

to an affected area? [ ] No Return date
Has the patient had contact with a confirmed [ ] Yes [ ] No [ ] Unknown
case? [ ] Other exposure:_____________________________
Additional
Comments

Requested by: Verified by:

______________________________________________ ______________________________________________
Name and Signature Name and Signature of RESU Representative