Date: 11/24/2020

DIAGNOSTIC REQUEST FORM

Patient Details: REQUESTER DETAILS:

Name: Patient X Name:
Address: Panay, Magsingal Address:
Age: 90
Gender: FEMALE

o CBC
o U/A
o NA, K, BUN, CREA
o AST ALT
o FBS
o 12 lead ECG
o Chest PA
o Rapid antigen for SARCOV19
o Plain Cranial CT Scan
o CBG

ADMISSION DIAGNOSIS: CVD BLEED

Requester’s Signature: ________________________________