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    MMMH-M-PAL-QP-003 Form1 Rev.1-Clinical Laboratory Request: City of Batac, Ilocos Norte, Philippines

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    Wyn Agustin
    This document is a clinical laboratory request form from Mariano Marcos Memorial Hospital and Medical Center. It lists over 50 different laboratory tests that can be requested, organized into categories like hematology, clinical chemistry, coagulation studies, and serology/immunology. The form provides spaces for patient details, requesting physician information, and test selection. It specifies that separate forms are needed for certain test types like bacteriology and surgical pathology. It also notes that stat requests require justification and extra charges.

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    MMMH-M-PAL-QP-003 Form1 Rev.1-Clinical Laboratory Request: City of Batac, Ilocos Norte, Philippines

    Uploaded by

    Wyn Agustin
    91 views1 page
    This document is a clinical laboratory request form from Mariano Marcos Memorial Hospital and Medical Center. It lists over 50 different laboratory tests that can be requested, organized into categories like hematology, clinical chemistry, coagulation studies, and serology/immunology. The form provides spaces for patient details, requesting physician information, and test selection. It specifies that separate forms are needed for certain test types like bacteriology and surgical pathology. It also notes that stat requests require justification and extra charges.

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    This document is a clinical laboratory request form from Mariano Marcos Memorial Hospital and Medical Center. It lists over 50 different laboratory tests that can be requested, organized into categories like hematology, clinical chemistry, coagulation studies, and serology/immunology. The form provides spaces for patient details, requesting physician information, and test selection. It specifies that separate forms are needed for certain test types like bacteriology and surgical pathology. It also notes that stat requests require justification and extra charges.

    Copyright:

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

    MMMH-M-PAL-QP-003 Form1 Rev.1-Clinical Laboratory Request: City of Batac, Ilocos Norte, Philippines

    Uploaded by

    Wyn Agustin
    This document is a clinical laboratory request form from Mariano Marcos Memorial Hospital and Medical Center. It lists over 50 different laboratory tests that can be requested, organized into categories like hematology, clinical chemistry, coagulation studies, and serology/immunology. The form provides spaces for patient details, requesting physician information, and test selection. It specifies that separate forms are needed for certain test types like bacteriology and surgical pathology. It also notes that stat requests require justification and extra charges.

    Copyright:

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

    MMMH-M-PAL-QP-003 Form1 Rev.

    1- Clinical Laboratory Request


    MARIANO MARCOS MEMORIAL HOSPITAL AND MEDICAL CENTER
    Department of Pathology and Laboratories
    City of Batac, Ilocos Norte, Philippines
    Contact Details: Direct Line: (077)6000105; Trunk Line: (077)7923133 loc. 102: Email:mmmh.lab@gmail.com
    CLINICAL LABORATORY REQUEST
    Note:
    REQUESTING PHYSICIAN MUST PROVIDE TO PATIENT CORRECT PRE-ANALYTIC INSTRUCTIONS PRIOR RO LABORATORY EXAMINATION. USE SEPARATE RESPECTIVE REQUESTS FOR
    THE FOLLOWING: BACTERIOLOGY LABORATORY REQYEST, CROSS-MATCHING, SURGICAL PATHOLOGY, PAPS, FNAB, PERIPHERLA BLOOD SMEAR.
    STAT REQUEST WILL NO BE PROCESSED UNLESS JUSTIFIED BY THE REQUESTING PHYSICIAN AND SHALL BE CHARGED ACCORDINGLY.

    PATIENT’S COMPLETE NAME (FIRST NAME, MIDDLE NAME, LAST NAME) Please print AGE SEX DATE OF BIRTH DATE AND TIME
    REQUESTED:
    HOSPITAL NUMBER COMPLETE ADDRESS: PATIENT’S CONTACT NUMBER (IF AVAILABLE)

    REQUESTING PHYSICIAN: REQUEST PREPARED BY: CLINICAL DIAGNOSIS


    ߛ
    ROUTINE ߛ
    󠇯 STAT
    (SIGNATURE OVER PRINTED NAME) (SIGNATURE OVER PRINTED NAME) JUSTIFIATION:
    LOCATION ____ OPD DEPARTMENT: ____ MEDICINE ____ ENT _____ OPTHALMOLOGY MSS CLASSIFICATION
    ____ ER ____ SURGERY ____ PEDIATRICS _____ HEMODIALYSIS
    ____ IN-PATIENT WARD/ROOM/BED NO.____ ____ ORTHOPEDICS ____ OB-GYN _____ FAMILY MEDICINE
    ********* FOR LABORATORY USE ONLY *********
    DATE AND TIME REQUEST REQUEST RECEIVED BY CHARGE SLIP PREPARED BY/ DATE AND TIME SPECIMEN SPECIMEN COLLECTED/ RECEIVED PATEINT’S ENTRY NO.
    RECEIVED CHARGE SLIP NO. CPOLLECTED/ACCEPTED BY

    *****Instruction: PLEASE CROSS OUT THE LEFT BOX BESIDE THE DESIRED TEST

    HEMATOLOGY Total Cell Count PANCREATIC PROFILE HEPATITIS C


    Complete Blood Count Differential Count Amylase Anti-HCV Screening
    Hemoglobin Glucose Lipase Anti-HCV ECLIA/EIA
    Hematocrit Protein LIPID PROFILE THYROID FUNCTION TEST
    Platelet count LDH Total Cholesterol T3
    Clotting Time CLINICAL CHEMISTRY Triglyceride T4
    Bleeding Time BONE/ JOINT ARTHRITIS TEST HDL- Cholesterol FT3
    Clot Retraction Time Blood Uric Acid LDL – Cholesterol FT4
    ABO-Rh Typing Rheumatoid Factor LIVER FUNCTION PROFILE TSH
    COAGULATION STUDIES CARDIAC MARKERS Total Protein TUMOR MARKERS
    Prothrombin Time AST/SGOT Albumin AFP
    APTT CK-MB Direct Bilirubin Beta-HCG
    Fibrinogen Trop-T quantitative Total Bilirubin CEA
    ANEMIA WORK UP Trop-I quantitative TEST FOR LIVER INJURY CA 19-9
    Iron DIABETIC PROFILE AST/SGOT PSA
    Total Iron Binding Capacity Fasting Blood Sugar/ FBS ALT/ SGPT CA 125
    Unsaturated Iron Binding Capacity Random Blood Sugar/ RBS Alkaline Phosphatase/ALP SLE WORK-UP
    Folate OGTT _____75 g _____100 g LDH Anti-Nuclear Antibody
    Ferritin OGCT _____ 50g _____75 g SEROLOGY/ IMMUNOLOGY SYPHILIS WORK UP
    BLOOD BANKING HbA1C DENGUE WORK UP Anti T. pallidum rapid test
    Direct Coomb’s test 2-HR Post-Prandial Blood Sugar DENGUE NS1 Antigen TPHA
    Indirect Coob’s test Insulin Dengue IgG/IgM
    DRUG TESTING LABORATORY Urine Ketone HIV TESTING OTHER TEST AVAILABLE
    Cannabinoids ELECTROLYTES Anti-HIV-1/ HIV-2 Screening/Rapid Complement3 (C3)
    Methamphetamine Sodium Anti-HIV-1/ HIV-2 EIA C-Reactive Protein
    A.U.B.F./ PARASITOLOGY Potassium HEPATITIS VIRUS INFECTION MARKERS Anti-streptolysin O (ASO)
    24-h Urine HCG Titer ___Ionized/ ____Total Calcium HEPATITIS A Salmonella IgG/IgM
    Pregnancy test Chloride
    Routine stool examination Magnesium
    Routine Urinalysis Phosphorous

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