Republic of the Philippines

Department of Health
SAN LAZARO HOSPITAL
Manila, Philippines
Telephone Nos.: 8732-3776 to 78; 8732-3106
E-mail Address: sanlazarohospital@yahoo.com
Official Website: www.slh.doh.gov.ph
SUB-NATIONAL LABORATORY FOR EMERGING AND RE-EMERGING INFECTIOUS DISEASES (EREID)
LABORATORY REFERRAL REQUEST FORM FOR COVID-19
Completely fill-out the data in this form
I. PATIENT INFORMATION: (to be filled-out by requisitioner) To be filled- out by San Lazaro Hospital Sub-National
Name: (First, Middle, Last) Laboratory for COVID 19 Testing Pre-Analytical Staff
SLH - SPECIMEN NO.
SLH - HOSPITAL ID NO.

Address: (Street,Barangay, District, Municipality, Province, Region) Date of Birth: SEX: AGE:
/ M ________
MM / DD / YYYY
F (YY / MM)
Location/Classification: Date of Admission:
Contact Number: E-mail: Referral / /____
(MM / DD / YYYY)
OPD
PhilHealth ID Number Used: Date of Onset of Illness:
In-Patient ____/____/______
(MM / DD / YYYY)
Clinical Impression:
(Refer to CIF for each case definition)

Suspect Probable Confirmed Contact Tracing Others (Please Specify):________________

Priority Sub-Group:
a. ) Severe / Critical
b. ) Patients / Health Care Workers with mild symptoms / history of travel / exposure with known Covid 19 case
and considered vulnerable.
c. ) Patients / Health Care Workers with mild symptoms but not vulnerable
d. ) Patients / Health Care Workers with no symptoms but with history of travel / exposure with known Covid 19
case.
e. ) Health Care Workers who are indirectly involved in the Health Care response.
II. EQUISITIONER INFORMATION: (To be filled-out by requisitioner)
Details of Requesting Institution:
Name in print and signature of requesting
Name of facility:______________________________________ physician:
Address:____________________________________________
Tel. No. ________________ Mobile No. ____________________
Specimen Collected by: (name and signature)
Institution’s E-mail address: _____________________________
(Note: Results will be reported based on DOH and SLH-SNL institutional guidelines)
Instructions to referring institution/facility:
III. SPECIMEN INFORMATION (To be filled-out by SLH-SNL)
(to be filled-out by the laboratory staff of the referring institution)

Specimen Type: Date Collected:

(please check one)
Specimen is stored Specimen Evaluation:
 NPS and OPS in single Time Collected: prior to transport in: (to be filled-out by SLH-SNL)
UTM/VTM
 NPS only in UTM/VTM
Order of Specimen:
Room temperature ACCEPTABLE
✔ OPS only in UTM/VTM 1st

2nd
Refrigerator
 Bronchoalveolar Lavage (BAL)
NOT ACCEPTABLE
3rd Freezer
 Sputum Reason/s

Endotracheal Aspirate Others:_____

 (Please Specify)

Date and Time Received and Name of SLH staff (name in print and signature)
Remark/s:

For inquiries, contact SLH Department of Laboratories Tel. No. (02)53102005 or send an e-mail to: slhlab.covid19@yahoo.com