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    Lab Request

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    Cooper Nikko Chavez
    This document is a laboratory and imaging test request form from Socorro Health Center in Quezon City, Philippines. It includes the patient's name, age, address, and date. It lists several common laboratory tests including complete blood count, urinalysis, and blood chemistry panels. It also lists various imaging tests such as x-rays, ultrasounds, and ECG. The form is addressed to Cooper Nikko C. Chavez, MD, who is requesting the tests.

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    Lab Request

    Uploaded by

    Cooper Nikko Chavez
    5 views5 pages
    This document is a laboratory and imaging test request form from Socorro Health Center in Quezon City, Philippines. It includes the patient's name, age, address, and date. It lists several common laboratory tests including complete blood count, urinalysis, and blood chemistry panels. It also lists various imaging tests such as x-rays, ultrasounds, and ECG. The form is addressed to Cooper Nikko C. Chavez, MD, who is requesting the tests.

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    This document is a laboratory and imaging test request form from Socorro Health Center in Quezon City, Philippines. It includes the patient's name, age, address, and date. It lists several common laboratory tests including complete blood count, urinalysis, and blood chemistry panels. It also lists various imaging tests such as x-rays, ultrasounds, and ECG. The form is addressed to Cooper Nikko C. Chavez, MD, who is requesting the tests.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    5 views5 pages

    Lab Request

    Uploaded by

    Cooper Nikko Chavez
    This document is a laboratory and imaging test request form from Socorro Health Center in Quezon City, Philippines. It includes the patient's name, age, address, and date. It lists several common laboratory tests including complete blood count, urinalysis, and blood chemistry panels. It also lists various imaging tests such as x-rays, ultrasounds, and ECG. The form is addressed to Cooper Nikko C. Chavez, MD, who is requesting the tests.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 5

    Republic of the Philippines

    Quezon City Health Department


    SOCORRO HEALTH CENTER
    139, 15th Avenue, Socorro, Quezon City
    socorrohc.cityhealth@quezoncity.gov.ph

    Name: _______________________________ Age/Sex: _________

    Address: _____________________________ Date: ____________

    LABORATORY IMAGING
    Ο CBC with PC X-ray: __________________
    Ο Urinalysis
    Ultrasound: _____________
    Ο Fecalysis
    Ο Fasting Blood Sugar
    Others:
    Ο HbA1c
    Ο 12L ECG
    Ο Blood Urea Nitrogen
    Ο Pregnancy Test
    Ο Creatinine
    Ο HBsAg
    Ο Blood Uric Acid
    Ο VDRL/RPR
    Ο Lipid Profile
    Ο OGTT
    Ο Total Cholesterol
    Ο Blood Typing
    Ο AST/SGOT
    Ο HIV screening
    Ο ALT/SGPT
    Ο Pap smear
    Ο Sodium
    Ο Potassium

    OTHERS:

    _____________________________________________________________

    _____________________________________________________________

    Requested by:

    Cooper Nikko C. Chavez, MD


    Republic of the Philippines
    Quezon City Health Department
    SOCORRO HEALTH CENTER
    139, 15th Avenue, Socorro, Quezon City
    socorrohc.cityhealth@quezoncity.gov.ph
    Medical Officer - Lic. No. 0159678
    Name: _______________________________ Age/Sex: _________

    Address: _____________________________ Date: ____________

    LABORATORY IMAGING
    Ο CBC with PC X-ray: __________________
    Ο Urinalysis
    Ultrasound: _____________
    Ο Fecalysis
    Ο Fasting Blood Sugar
    Others:
    Ο HbA1c
    Ο 12L ECG
    Ο Blood Urea Nitrogen
    Ο Pregnancy Test
    Ο Creatinine
    Ο HBsAg
    Ο Blood Uric Acid
    Ο VDRL/RPR
    Ο Lipid Profile
    Ο OGTT
    Ο Total Cholesterol
    Ο Blood Typing
    Ο AST/SGOT
    Ο HIV screening
    Ο ALT/SGPT
    Ο Pap smear
    Ο Sodium
    Ο Potassium

    OTHERS:

    _____________________________________________________________

    _____________________________________________________________

    Requested by:

    Cooper Nikko C. Chavez, MD


    Republic of the Philippines
    Quezon City Health Department
    SOCORRO HEALTH CENTER
    139, 15th Avenue, Socorro, Quezon City
    socorrohc.cityhealth@quezoncity.gov.ph
    Medical Officer - Lic. No. 0159678

    Name: _______________________________ Age/Sex: _________

    Address: _____________________________ Date: ____________

    LABORATORY IMAGING
    Ο CBC with PC X-ray: __________________
    Ο Urinalysis
    Ultrasound: _____________
    Ο Fecalysis
    Ο Fasting Blood Sugar
    Others:
    Ο HbA1c
    Ο 12L ECG
    Ο Blood Urea Nitrogen
    Ο Pregnancy Test
    Ο Creatinine
    Ο HBsAg
    Ο Blood Uric Acid
    Ο VDRL/RPR
    Ο Lipid Profile
    Ο OGTT
    Ο Total Cholesterol
    Ο Blood Typing
    Ο AST/SGOT
    Ο HIV screening
    Ο ALT/SGPT
    Ο Pap smear
    Ο Sodium
    Ο Potassium

    OTHERS:

    _____________________________________________________________

    _____________________________________________________________

    Requested by:
    Republic of the Philippines
    Quezon City Health Department
    SOCORRO HEALTH CENTER
    139, 15th Avenue, Socorro, Quezon City
    socorrohc.cityhealth@quezoncity.gov.ph
    Cooper Nikko C. Chavez, MD
    Medical Officer - Lic. No. 0159678

    Name: _______________________________ Age/Sex: _________

    Address: _____________________________ Date: ____________

    LABORATORY IMAGING
    Ο CBC with PC X-ray: __________________
    Ο Urinalysis
    Ultrasound: _____________
    Ο Fecalysis
    Ο Fasting Blood Sugar
    Others:
    Ο HbA1c
    Ο 12L ECG
    Ο Blood Urea Nitrogen
    Ο Pregnancy Test
    Ο Creatinine
    Ο HBsAg
    Ο Blood Uric Acid
    Ο VDRL/RPR
    Ο Lipid Profile
    Ο OGTT
    Ο Total Cholesterol
    Ο Blood Typing
    Ο AST/SGOT
    Ο HIV screening
    Ο ALT/SGPT
    Ο Pap smear
    Ο Sodium
    Ο Potassium

    OTHERS:

    _____________________________________________________________

    _____________________________________________________________

    Requested by:
    Republic of the Philippines
    Quezon City Health Department
    SOCORRO HEALTH CENTER
    139, 15th Avenue, Socorro, Quezon City
    socorrohc.cityhealth@quezoncity.gov.ph

    Cooper Nikko C. Chavez, MD


    Medical Officer - Lic. No. 0159678

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