& Addrcss :

Test Requisition Forrn Visit No.

Name

NPLRC KATHMANDU
Maharajgunj-03, Kathmandu'
Nepal ilt I lil ill lllllllllllillllllllllllllllil lll
C.C.
KTM221268310
NPLRC KATHMANDU
Information in TRF is uired to rocess
29-Dec-2022 04:57PM
Patient Information
Fatient Name: MT.ARIIN BHUJEL
tr Male I Female

Height: Address: ktm

Age 22Yl]vIale
Weight:
Mob:9816184174
Email:

Physician Information
Credentials
Name: DT.ANJAN SHRESTHA

Institution:
Mob:9816184174
Email:

Test Description
(PNH) CONFIRMATORY TEST
05326 - PAROXYSMAL NOCTURNAL HEMOGLOBINUzuA

Clinical Information
a. Provisional Diagnosis:

b. H/O Meditation Yes/No

c. If yes,Name:

d. Status of Meditation On going/Terminated

e. If on going,duation:

f. If terminated,when

g.LMP'
Date and time of collection required to process specimens
URINE: Collectio Date: Time E ,c.Nr flrlvl STOOL 1: Collectio Date: Time: fl unr E rrrr

IIas urine been frozen? flv.. E No sTool, 2 Collectio Date: Time: I au f] pttt

24 hours urine volumel

BLOOD (R) Collectio Date Time: f| ,trur D pitr SPUTUMI: Collectio Date: Time: E*rnpvI
BLOOD (F7PP) Collectio Date: rime: I au f]Pryt SPUTUM 2: Collectio Date: Time: fl arnr npu
FLUIDS ColtectioDate: Time: I awr il Pvr SPUTUM 3: Collectio Date Time: fl .trvr n pu
all medical benilits be paid directly to National'Pat'tl
aly
of this Test Requieition From. I authorize payment of
Iagree to have requested lad work performed on receiPt
and information about me to rclease any information nccessary for this claim' I permit a coPy ofthis to 6e uped in
of medical information about me to release
Authorised Signature
Patient Signature