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  • Lab Request #2507613

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    staff.sriprima
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    This document is a laboratory investigation request form containing information about a patient and requested medical tests. It includes the patient's name, date of birth, age, sex, date and time their specimen was taken, and the type of specimen. The form lists the required tests, including a full blood count, lipid profile, HbA1c, renal profile, and urine biochemistry. It also includes information about the requesting doctor, sample collection details, and notes about reporting critical results to the doctor and transferring results to the PeKa B40 Benefit Management System.

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    This document is a laboratory investigation request form containing information about a patient and requested medical tests. It includes the patient's name, date of birth, age, sex, date and time their specimen was taken, and the type of specimen. The form lists the required tests, including a full blood count, lipid profile, HbA1c, renal profile, and urine biochemistry. It also includes information about the requesting doctor, sample collection details, and notes about reporting critical results to the doctor and transferring results to the PeKa B40 Benefit Management System.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    7 views1 page

    Lab Request #2507613

    Uploaded by

    staff.sriprima
    This document is a laboratory investigation request form containing information about a patient and requested medical tests. It includes the patient's name, date of birth, age, sex, date and time their specimen was taken, and the type of specimen. The form lists the required tests, including a full blood count, lipid profile, HbA1c, renal profile, and urine biochemistry. It also includes information about the requesting doctor, sample collection details, and notes about reporting critical results to the doctor and transferring results to the PeKa B40 Benefit Management System.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 1

    ProtectHealth Corporation Sdn Bhd

    (1212734 -T}
    F01 & F02, 1st Floor, Block 2300
    Century Square, Jalan Usahawan
    63000 CyberJaya, Selangor
    T +603 8687 2500
    F +603 8687 2599
    Peduli Kesihatan untuk Kumpulan B40 E info@protecthealth.com.my
    Laboratory Investigation Request Form www.protecthealth.com.my

    Beneficiary Information
    New IC number 820112025653
    Full name K.JOHANN BIN TONY ZAINUDDIN
    Date of birth Jan 12, 1982
    Age 42
    Sex Male

    Test Information
    Date and time specimen taken Jan 25, 2024 21:00
    Specimen type Non-fasting
    Testing laboratory Innoquest Pathology/Gribbles Pathology (Petaling Jaya HQ)

    Remark

    Blood Specimen
    Full blood count (FBC)
    Lipid profile
    Glycosylated haemoglobin A1c (HbA1c)
    Tests required
    Renal profile (RP) with estimated glomerular filtration rate (eGFR)

    *All listed tests are mandatory


    Urine Specimen
    Urine biochemistry

    Requesting Doctor
    Doctor’s Signature and Stamp Clinic Stamp and Phone Number

    Sample Collection
    Date of Collection Time of Collection

    Notes
    Please call the requesting doctor immediately in case of any clinically critical results.
    Lab must transfer results to the PeKa B40 Benefit Management System (BMS) an provide two
    (2) hardcopies of lab report to clinic within three (3) working days.
    Reference number: 2507613
    PIN: 148233

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