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  • Lab Req Form

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    Dan Kisa
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    St. Bakhita Mission Health Centre provides laboratory request and results forms for patients. The forms collect the patient's name, age, sex, personal identification number, ward, medical history, diagnosis, and the requesting clinician's signature and date. The form also lists spaces for the date, required test, results, and laboratory technician's signature to record the results of any tests performed.

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    LAB REQ FORM

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    St. Bakhita Mission Health Centre provides laboratory request and results forms for patients. The forms collect the patient's name, age, sex, personal identification number, ward, medical history, diagnosis, and the requesting clinician's signature and date. The form also lists spaces for the date, required test, results, and laboratory technician's signature to record the results of any tests performed.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    6 views1 page

    Lab Req Form

    Uploaded by

    Dan Kisa
    St. Bakhita Mission Health Centre provides laboratory request and results forms for patients. The forms collect the patient's name, age, sex, personal identification number, ward, medical history, diagnosis, and the requesting clinician's signature and date. The form also lists spaces for the date, required test, results, and laboratory technician's signature to record the results of any tests performed.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    St. Bakhita Mission Health Centre St.

    Bakhita Mission Health Centre


    P.O. Box 38-50207 MISIKHU P.O. Box 38-50207 MISIKHU
    Laboratory Request Laboratory Request
    (Request and Results) (Request and Results)
    Name …………………………………………….Age………………….….Sex……..………. Name …………………………………………….Age……………….Sex…………….…….
    PIN…………………………………………………Ward…………………..…………………… PIN………………………………………………..……Ward………………………..…………
    History (including drugs used…………………………………………………………… History (including drugs used……………………………………………………………
    …………………………………………………………………………………………………………. ………………………………………………………………………………………………………….
    …………………………………………………………………………………………………………. ………………………………………………………………………………………………………….
    Diagnosis………………………………………………………………………………………….. Diagnosis…………………………………………………………………………………………..
    Requesting Clinician’s Signature……………………..…….Date…………………… Requesting Clinician’s Signature……………………..…….Date……………………
    Date Test Required Results Lab Tech Date Test Required Results Lab Tech
    Signature Signature

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