Lab. No.

CLINICAL LABORATORY REQUEST

Date Requested: 04/19/2020

Patient’s Name: Tabudlo Zack j

Last Name First Name Middle Name

Age/Sex: 1 year old/ Male Health Record Number: _______________

Date of Birth: Ward/Bed No.: COVID Ward

( ) OPD ( ) PhilHealth ( ) Pay ( ) Charity/Service

Admission Date: 04/19/2020

Clinical Diagnosis:

Specimen: Blood

Examination/s Desired:

CBC,BT STAT

T# _______ OR No: ________ Dr. Macaayan , M.D.

Requesting PhysicianSign/Over Printed Name
Lab. No.

CLINICAL LABORATORY REQUEST

Date Requested: 04/19/2020

Patient’s Name: Tabudlo Zack j

Last Name First Name Middle Name

Age/Sex: 1 year old/ Male Health Record Number: _______________

Date of Birth: Ward/Bed No.: COVID Ward

( ) OPD ( ) PhilHealth ( ) Pay ( ) Charity/Service

Admission Date: 04/19/2020

Clinical Diagnosis:

Specimen: Blood

Examination/s Desired:

Blood CS STAT

T# _______ OR No: ________ Dr. Riego , M.D.

Requesting PhysicianSign/Over Printed Name
Lab. No.

CLINICAL LABORATORY REQUEST

Date Requested: 04/19/2020

Patient’s Name: Tabudlo Zack j

Last Name First Name Middle Name

Age/Sex: 1 year old/ Male Health Record Number: _______________

Date of Birth: Ward/Bed No.: COVID Ward

( ) OPD ( ) PhilHealth ( ) Pay ( ) Charity/Service

Admission Date: 04/19/2020

Clinical Diagnosis:

Specimen: Blood

Examination/s Desired:

ABG STAT

T# _______ OR No: ________ Dr. Macaayan , M.D.

Requesting PhysicianSign/Over Printed Name

Lab. No.

CLINICAL LABORATORY REQUEST

Date Requested: 04/19/2020

Patient’s Name: Tabudlo Zack j

Last Name First Name Middle Name

Age/Sex: 1 year old/ Male Health Record Number: _______________

Date of Birth: Ward/Bed No.: COVID Ward

( ) OPD ( ) PhilHealth ( ) Pay ( ) Charity/Service

Admission Date: 04/19/2020

Clinical Diagnosis:

Specimen: Blood

Examination/s Desired:

serum electrolytes STAT

T# _______ OR No: ________ Dr. Macaayan , M.D.

Requesting PhysicianSign/Over Printed Name

Lab. No.

CLINICAL LABORATORY REQUEST

Date Requested: 04/19/2020

Patient’s Name: Tabudlo Zack j

Last Name First Name Middle Name

Age/Sex: 1 year old/ Male Health Record Number: _______________

Date of Birth: Ward/Bed No.: COVID Ward

( ) OPD ( ) PhilHealth ( ) Pay ( ) Charity/Service

Admission Date: 04/19/2020

Clinical Diagnosis:

Specimen: Fecal

Examination/s Desired:

stool exam

T# _______ OR No: ________ Dr. Macaayan , M.D.

Requesting PhysicianSign/Over Printed Name

Lab. No.

CLINICAL LABORATORY REQUEST

Date Requested: 04/19/2020

Patient’s Name: Tabudlo Zack j

Last Name First Name Middle Name

Age/Sex: 1 year old/ Male Health Record Number: _______________

Date of Birth: Ward/Bed No.: COVID Ward

( ) OPD ( ) PhilHealth ( ) Pay ( ) Charity/Service

Admission Date: 04/19/2020

Clinical Diagnosis:

Specimen: Blood

Examination/s Desired:

HGT
T# _______ OR No: ________ Dr. Macaayan , M.D.
Requesting PhysicianSign/Over Printed Name
Lab. No.

CLINICAL LABORATORY REQUEST

Date Requested: 04/19/2020

Patient’s Name: Tabudlo Zack j

Last Name First Name Middle Name

Age/Sex: 1 year old/ Male Health Record Number: _______________

Date of Birth: Ward/Bed No.: COVID Ward

( ) OPD ( ) PhilHealth ( ) Pay ( ) Charity/Service

Admission Date: 04/19/2020

Clinical Diagnosis:

Specimen: Urine

Examination/s Desired:

Urinalysis

T# _______ OR No: ________ Dr. Macaayan , M.D.

Requesting PhysicianSign/Over Printed Name
Lab. No.

CLINICAL LABORATORY REQUEST

Date Requested: 04/19/2020

Patient’s Name: Tabudlo Zack j

Last Name First Name Middle Name

Age/Sex: 1 year old/ Male Health Record Number: _______________

Date of Birth: Ward/Bed No.: COVID Ward

( ) OPD ( ) PhilHealth ( ) Pay ( ) Charity/Service

Admission Date: 04/19/2020

Clinical Diagnosis:

Specimen: Oropharyngeal Swab

Examination/s Desired:

RT-PCR

T# _______ OR No: ________ Dr. Macaayan , M.D.

Requesting PhysicianSign/Over Printed Name