QUIJANO CLINIC & HOSPITAL, INC. QUIJANO CLINIC & HOSPITAL, INC.
National Highway, Tacurong City National Highway, Tacurong City
CLINICAL LABORATORY CLINICAL LABORATORY
Date: _____________, 20____ Date: _____________, 20____
Name: _____________________________ Age: ____ Sex: ____ Name: _____________________________ Age: ____ Sex: ____
[ ] Single [ ] Married [ ] Widow [ ] Single [ ] Married [ ] Widow
Birthdate: ______________________Services: ___ Rm.No.: ___ Birthdate: ______________________Services:____ Rm.No.: ___
Diagnosis: _________________________ [ ] Routine [ ] Stat Diagnosis: _________________________ [ ] Routine [ ] Stat
Hematology Clinical Chemistry Hematology Clinical Chemistry
[ ] CBC [ ] FBS [ ] CBC [ ] FBS
[ ] PLATELET [ ] Total [ ] PLATELET [ ] Total
[ ] Hgb/Hct Cholesterol [ ] Hgb/Hct Cholesterol
[ ] ESR (Erythrocyte [ ] Serum Uric Acid [ ] ESR (Erythrocyte [ ] Serum Uric Acid
Sedimentation Rate) [ ] Creatinine Sedimentation Rate) [ ] Creatinine
[ ] Others _____________ [ ] Triglycerides [ ] Others _____________ [ ] Triglycerides
[ ] SGPT / ALT [ ] SGPT / ALT
Clinical Microscopy [ ] Total Protein Clinical Microscopy [ ] Total Protein
[ ] Urinalysis [ ] Gram staining [ ] Albumin [ ] Urinalysis [ ] Gram staining [ ] Albumin
[ ] Fecalysis [ ]10%KOH [ ] TPAG [ ] Fecalysis [ ]10%KOH [ ] TPAG
[ ] BUN [ ] BUN
Serology/Immunology [ ] Complete Serology/Immunology [ ] Complete
[ ] HBsAg [ ]Pregnancy Blood Chemistry [ ] HBsAg [ ]Pregnancy Blood Chemistry
[ ] Syphilis/VDRL Test [ ] Lipid Profile [ ] Syphilis/VDRL Test [ ] Lipid Profile
[ ] Dengue Test [ ] Blood [ ] Others ______ [ ] Dengue Test [ ] Blood [ ] Others ______
[ ] Cross Matching Typing [ ] Cross Matching Typing
[ ]BSMP [ ] Typhidot [ ]BSMP [ ] Typhidot
[ ] Occult Blood [ ] Occult Blood
[ ] Others:_____________________________________ [ ] Others:_____________________________________
Requesting Physician: ____________________________ Requesting Physician: ____________________________
_______________________ _______________________
Nurse Signature Nurse Signature
QUIJANO CLINIC & HOSPITAL, INC. QUIJANO CLINIC & HOSPITAL, INC.
National Highway, Tacurong City National Highway, Tacurong City
CLINICAL LABORATORY CLINICAL LABORATORY
Date: _____________, 20____ Date: _____________, 20____
Name: _____________________________ Age: ____ Sex: ____ Name: _____________________________ Age: ____ Sex: ____
[ ] Single [ ] Married [ ] Widow [ ] Single [ ] Married [ ] Widow
Birthdate: ______________________Services:____ Rm.No.: ___ Birthdate: ______________________Services: ___ Rm.No.: ___
Diagnosis: _________________________ [ ] Routine [ ] Stat Diagnosis: _________________________ [ ] Routine [ ] Stat
Hematology Clinical Chemistry Hematology Clinical Chemistry
[ ] CBC [ ] FBS [ ] CBC [ ] FBS
[ ] PLATELET [ ] Total [ ] PLATELET [ ] Total
[ ] Hgb/Hct Cholesterol [ ] Hgb/Hct Cholesterol
[ ] ESR (Erythrocyte [ ] Serum Uric Acid [ ] ESR (Erythrocyte [ ] Serum Uric Acid
Sedimentation Rate) [ ] Creatinine Sedimentation Rate) [ ] Creatinine
[ ] Others _____________ [ ] Triglycerides [ ] Others _____________ [ ] Triglycerides
[ ] SGPT / ALT [ ] SGPT / ALT
Clinical Microscopy [ ] Total Protein Clinical Microscopy [ ] Total Protein
[ ] Urinalysis [ ] Gram staining [ ] Albumin [ ] Urinalysis [ ] Gram staining [ ] Albumin
[ ] Fecalysis [ ]10%KOH [ ] TPAG [ ] Fecalysis [ ]10%KOH [ ] TPAG
[ ] BUN [ ] BUN
Serology/Immunology [ ] Complete Serology/Immunology [ ] Complete
[ ] HBsAg [ ]Pregnancy Blood Chemistry [ ] HBsAg [ ]Pregnancy Blood Chemistry
[ ] Syphilis/VDRL Test [ ] Lipid Profile [ ] Syphilis/VDRL Test [ ] Lipid Profile
[ ] Dengue Test [ ] Blood [ ] Others ______ [ ] Dengue Test [ ] Blood [ ] Others ______
[ ] Cross Matching Typing [ ] Cross Matching Typing
[ ]BSMP [ ] Typhidot [ ]BSMP [ ] Typhidot
[ ] Occult Blood [ ] Occult Blood
[ ] Others:_____________________________________ [ ] Others:_____________________________________
Requesting Physician: ____________________________ Requesting Physician: ____________________________
_______________________ _______________________
Nurse Signature Nurse Signature
QUIJANO CLINIC & HOSPITAL, INC. QUIJANO CLINIC & HOSPITAL, INC.
National Highway, Tacurong City National Highway, Tacurong City
CLINICAL LABORATORY CLINICAL LABORATORY
Date: _____________, 20____ Date: _____________, 20____
Name: _____________________________ Age: ____ Sex: ____ Name: _____________________________ Age: ____ Sex: ____
[ ] Single [ ] Married [ ] Widow [ ] Single [ ] Married [ ] Widow
Address: ____________________________________________ Address: ____________________________________________
Services: ________________________Room No.: ___________ Services: ________________________Room No.: ___________
Clinical Diagnosis: _____________________________________ Clinical Diagnosis: _____________________________________
[ ] Routine [ ] Stat [ ] Routine [ ] Stat
Case No.: ____________________________________________ Case No.: ____________________________________________
SPECIMEN SPECIMEN
( ) URINE ____________________________________ ( ) URINE ____________________________________
( ) STOOL ____________________________________ ( ) STOOL ____________________________________
( ) BLOOD ___________________________________ ( ) BLOOD ___________________________________
______________________________________ ______________________________________
( ) ECG ______________________________________ ( ) ECG ______________________________________
( ) ______________________________________ ( ) ______________________________________
( ) OTHERS ___________________________________ ( ) OTHERS ___________________________________
Requesting Physician ___________________________________ Requesting Physician ___________________________________
__________________________ __________________________
Nurse Signature Nurse Signature
QUIJANO CLINIC & HOSPITAL, INC. QUIJANO CLINIC & HOSPITAL, INC.
National Highway, Tacurong City National Highway, Tacurong City
CLINICAL LABORATORY CLINICAL LABORATORY
Date: _____________, 20____ Date: _____________, 20____
Name: _____________________________ Age: ____ Sex: ____ Name: _____________________________ Age: ____ Sex: ____
[ ] Single [ ] Married [ ] Widow [ ] Single [ ] Married [ ] Widow
Address: ____________________________________________ Address: ____________________________________________
Services: ________________________Room No.: ___________ Services: ________________________Room No.: ___________
Clinical Diagnosis: _____________________________________ Clinical Diagnosis: _____________________________________
[ ] Routine [ ] Stat [ ] Routine [ ] Stat
Case No.: ____________________________________________ Case No.: ____________________________________________
SPECIMEN SPECIMEN
( ) URINE ____________________________________ ( ) URINE ____________________________________
( ) STOOL ____________________________________ ( ) STOOL ____________________________________
( ) BLOOD ___________________________________ ( ) BLOOD ___________________________________
______________________________________ ______________________________________
( ) ECG ______________________________________ ( ) ECG ______________________________________
( ) ______________________________________ ( ) ______________________________________
( ) OTHERS ___________________________________ ( ) OTHERS ___________________________________
Requesting Physician ___________________________________ Requesting Physician ___________________________________
__________________________ __________________________
Nurse Signature Nurse Signature
