LABORATORY REQUEST

CLINICAL LABORATORY REQUEST Lab No.

Date Requested: ___________

Patient’s Name: ________________________________________________

Last Name First Name Middle Name

Age/Sex: __________ Health Record Number: _______________

Date of Birth: ______ Ward/Bed No.: ______________________
( ) OPD ( ) PhilHealth ( ) Pay ( ) Charity/Service
Admission Date: ________________________________________________
Clinical Diagnosis: _______________________________________________
Specimen: _____________________________________________________
Examination/s Desired:

T# _______ OR No: ________ _____________________, M.D.

Requesting Physician
Sign Over Printed Name