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PATIENT REGISTRATION FORM

Full Name* Bernard Sotnas
Email address* dranrebsantos@gmail.com

Dr. referred by* Dr. Chloe Decker

Address 123 Santol, Tanauan City, Batangas

Phone No. 09954772814

Age 20

Sex* M
Birth Date* 11/01/99
Birth Place* Sto.tomas Next

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Name of Patient: Bogart Solmoro

Ref no. of Patient: 2018-1175

Date S.I No. Ref. Number Patient Name Age/Gender Test Requested Referred by: Notes
11/30/19 1234561 2018-11575 Bogart Solmoro M CBC Dr. Bornok Borgueta

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MANAGE DOCTOR
*Requesting Physician:
*Specialization:
*Licensed #:
*Name of Clinic/ Hospital:
Clinic Hours:
*Contact #:

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CLINICAL CHEMISTRY BLOOD BANKING

MICROBIOLOGY SEROLOGY
HEMATOLOGY CLINICAL MICROSCOPY

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HEMATOLOGY

COMPLETE BLOOD COUNT

BLOOD BANKING

SEROLOGY

HEMATOLOGY
CLINICAL MICROSCOPY

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COMPLETE BLOOD COUNT

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BLOOD BANKING
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HEMATOLOGY
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SEROLOGY
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CLINICAL MICROSCOPY
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HEMATOLOGY
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Test Name Amount (P) Test Requested

• Complete Blood Count (CBC) 750.00
• Erythrocyte Sedimentation Rate (ESR) 450.00
• Platelet Count 200.00
• Hemoglobin 200.00
• Reticulocyte Count 650.00

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HEMATOLOGY
Summary of Requested Test/s

Test Name Amount (P)

• Complete Blood Count (CBC) 750.00
• Erythrocyte Sedimentation Rate (ESR) 450.00
• Platelet Count 200.00
• Hemoglobin 200.00
• Reticulocyte Count 650.00
TOTAL BILL Php 2,250
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MASTER DATA
Name of Patient: .
RESULTS
Ref no. of Patient: Complete Blood Count
RESULT REFERENCE RANGE
Total Red Cell Count: 6.74 M/uL 4.7-6.10 M/uL
Total White Cell Count: 5.66 K/uL 4.8-10.8 K/uL
Total Platelet Count: 240 K/uL 130-400 K/uL
Hemoglobin: 12.68 g/dL 12.6-17.4 g/dL
Hematocrit: 50.7 % 37.0-51.0 %
MCV 93.0 fl 80.0-94.0 fl
MCH 30.87 pg 27.0-31.0 pg
MCHC 35.0 g/dL 33.0-37.0 g/dL

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