Doc.

No : LPL/CLC/QF/2806

LPL LAB NO.

AFFIX
TEST REQUISITION FORM BAR
PATIENT INFORMATION : CORP. : BILL TO :
PATIENT’S NAME
C. C. : R.C. C. :
(Block Letters)
Name & Address: Name & Address:
Patient’s Address: ......................................................................
.....................................................................................................
UID : ..........................................................................................
Phone No. : ................................................................................
Date of Birth : .................................. Male Female REFERRING DOCTOR:
Age : ................... Years ................... Months...................Days Doctor’s Name : .....................................................................
Height : .......Ft........cm Weight : ................... Kg. Phone No. ................................................City...........................

Test Code Test Description

SPECIMEN INFORMATION
Test Amount
Hospital / CC / PUP ............................

Drawn Date : ........................................

Time Drawn : .......................................

TOTAL
Discount Percent Gross Amount Payable TEMPERATURE SENT TEMPERATURE RECD.
Less Discount (if any) Frozen (< 2º Celsius) Frozen (< 2º Celsius)
Discount Details Net Amount Payable Gel Pack (2-8º Celsius) Gel Pack (2-8º Celsius)
Less Amount Paid
Balance Due Temp (18º - 22º Celsius) Temp (18º - 22º Celsius)
FOR REPEAT / FOLLOW – UP PATIENTS
TEST REQUIREMENTS : Please refer to the LPL Reference
Guide for correct test code / Name / specimen type Old LPL Lab No. .....................................................................
SPECIMEN TYPE ESSENTIAL CLINICAL INFORMATION
Qty. CSF Qty. (Please fill in whatever is relevant)
Serum
Tissue-Small/Medium* 1) Provisional diagnosis : .......................................
Plasma EDTA/FL/ CIT/ACD
Tissue-Large* 2) H/o Medication : Yes / No
FN Aspirate
W.Blood ACD Parafin Block* 3) If yes, Name: ........................................................
W.Blood EDTA Smear 4) Status of Medication : Ongoing / Terminated
W. Blood Fluoride Slide (H & E)*
5) If ongoing, Duration: ............................................
W. Blood Heparin Urine 1st Morn. /
Random Urine / 6) If terminated, When: ............................................
W. Blood Sodium Citrate
24 hrs Urine 7) Fasting Period ......................................................
Pus
BAL 8) 24 Hour Urine Volume .........................................
Fluid
Sputum Stool 9) For Histopathlogy / IHC, Attach Detailed History
Filter Paper Swab* 10) LMP (where applicable) .....................................
Bone Marrow Others* 11) Diabetes Status: Yes / No
*Mention Type / Site of Collection 12) Gestation Single / Twin
TICK SAMPLE WHICH EVER IS APPLICABLE. 13) Attach other relevant information .......................

Signature / Thumb impression of patient

Date :
* Signature of CC / PUP / Hospital
Date :

1.) It is mandatory to provide all the requested information to enable accurate and timely reporting.
* NOTE :
2.) Consent is hereby given to use my sample for Quality Assurance & Research purposes if needed.