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Tanga City Council Lab Request Form

The document is a laboratory request form for CD4 and CrAg tests from Tanga City Council. It includes sections for patient demographics, requested tests, and laboratory report details. The form requires signatures from the requester and the investigator, along with dates and times for the request and investigation.

Uploaded by

Grey Thomson
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29 views1 page

Tanga City Council Lab Request Form

The document is a laboratory request form for CD4 and CrAg tests from Tanga City Council. It includes sections for patient demographics, requested tests, and laboratory report details. The form requires signatures from the requester and the investigator, along with dates and times for the request and investigation.

Uploaded by

Grey Thomson
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

TANGA CITY COUNCIL

LABORATORY REQUEST FORM


CD4 AND CrAg TEST

Facility Name: ………………………………………………….


Facility Code: …………………………………………………..

PATIENT DEMOGRAPHIC
Patient UID: …………………………………………………….
Age: …………. Sex………... Address…………………………

TEST REQUESTED
CD4
CrAg

Requested by: …………………………………………...sign………


Requested date: …………………….. Time: ………………

LABORATORY REPORT ( to be filled in lab)


CD4 COUNT
CD4 % CD4 HB

CrAg results………………….

Investigator name:……………………………….. sign…………


Investigation date and time:………………………….

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