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Laboratory Request Form Template

This document is a laboratory and diagnostic request form containing fields to collect patient information such as name, birthdate, gender, contact details, and consent forms. It lists various basic and optional laboratory tests and diagnostic procedures that can be requested, including a urinalysis, complete blood count, fasting blood sugar, and electrocardiography. The form requires the patient's signature to certify the provided information is true and to consent to sharing results with their employer or physician. Spaces are included for reception, extraction, encoding, and releasing details to be filled out by the diagnostics laboratory.

Uploaded by

Eric Nagum
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
9K views1 page

Laboratory Request Form Template

This document is a laboratory and diagnostic request form containing fields to collect patient information such as name, birthdate, gender, contact details, and consent forms. It lists various basic and optional laboratory tests and diagnostic procedures that can be requested, including a urinalysis, complete blood count, fasting blood sugar, and electrocardiography. The form requires the patient's signature to certify the provided information is true and to consent to sharing results with their employer or physician. Spaces are included for reception, extraction, encoding, and releasing details to be filled out by the diagnostics laboratory.

Uploaded by

Eric Nagum
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
  • Laboratory Tests: Lists available laboratory tests such as Complete Blood Count, Fasting Blood Sugar, and Urinalysis.
  • Optional Diagnostic Procedures: Provides optional diagnostic procedures including ECG, Drug Test, and COVID-19 RT-PCR test that can be requested.
  • Patient Information: Collects basic patient information like name, age, and contact details for processing the laboratory request.

DATE:

ACCESSION NO.:
IMD Laboratory and Diagnostic Request Form

Please fill out this form completely, correctly and legibly. Thank you.

PATIENT INFORMATION
Last Name Gender: ☐ Male ☐ Female

First Name Birthdate:

Middle Name MM DD YY

Suffix (e.g. Jr., Sr., II) Age:

BLOOD EXTRACTION CONSENT FORM CHEST X-RAY CONSENT FORM (FEMALE PATIENT ONLY) Landline/ Mobile Numbers:
I, hereby allow the phlebotomist to extract blood from me for
clinical laboratory testing, in cases, wherein my blood does not Last menstrual period: ____________________________
meet the criteria for testing due to the following:

Hemolytic Overfasting Are you Pregnant? Yes ☐ No ☐


Icteric Underfasting Are you menopause? Yes ☐ No ☐ Company Name:
Lipemic QNS Have you undergone hysterectomy? Yes ☐ No ☐
I am willing to subject myself for repeat extraction.
Patient's Signature: Patient's Signature:

LABORATORY TESTS AND DIAGNOSTIC PROCEDURES

Basic 5 Routine Chemistry Optional


o Urinalysis o Fasting Blood Sugar o Electrocardiography (ECG)
o Fecalysis o Cholesterol o Drug Test
o Complete Blood Count o Triglycerides o Pap Smear
o Chest X-Ray o Lipoprotein o Hepa B Screening
o Physical Examination o Creatinine o Blood Typing
w/ Visual Acuity o Blood Uric Acid (BUA) o Rapid Antibody Test (COVID-19)
o Blood Urea Nitrogen (BUN) o RT-PCR (COVID-19)
o SGPT
Others

I certify that the answers and statements I provided are all true and correct to the best of my knowledge, and I understand that non-disclosure and/or misdeclaration of any of the above items
may be used against me in the appropriate forum under applicable laws. I give consent to New World Diagnostics, Inc. and the Examining Physician to provide and/or share to my employer,
attending physician, or authorized representative, all information regarding my health status, laboratory and diagnostic test results, and other related medical findings. I hereby release and
discharge New World Diagnostics Inc., its directors and employees, from any and all liabilities, claims, and/or damages, which may arise from the medical result/s issued by it.

Signature over Printed Name

DO NOT FILL OUT | FOR NWDI-IMD USE ONLY


RECEPTION DIAGNOSIS EXTRACTION
Received by: Extracted by: Last Meal: Medication:

Time: Time Extracted: LMP: Last Dose:

ENCODING RELEASING
Encoded by: Date: Checked by: Date: Time Released:

IMD-QF-005
Rev.4 May 2020

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