LAB NO: _____________________ LAB NO: __________________ LAB NO: ____________________

PBS PBS PBS

NAME OF PX: NAME OF PX: NAME OF PX:

A/S: A/S: A/S:

WARD: WARD: WARD:

DATE PREPARED: DATE PREPARED: DATE PREPARED:

PREPARED BY: PREPARED BY: PREPARED BY:

VERIFIED BY: VERIFIED BY: VERIFIED BY:

FORWARDED & LOGGED BY: FORWARDED & LOGGED BY: FORWARDED & LOGGED BY:

DATE PREPARED: ____________________

SAVE SMEAR
NAME: NAME: NAME:

A/S: A/S: A/S:

WARD: WARD: WARD:

MTOD: MTOD: MTOD:

DATE PREPARED: ____________________ DATE PREPARED: ____________________ DATE PREPARED: ____________________

SAVE SMEAR SAVE SMEAR BSMP

NAME: NAME: NAME:

A/S: A/S: A/S:

WARD: WARD: WARD:

DATE PREPARED: ____________________ DATE PREPARED: ____________________

BSMP BSMP