TEST REQUISITION FORM

PATHOLOGY

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Name : Mr.SANTOSH DUBEY Lab No : DEL010.144

Age/Sex : 45 Y 0 M 0 D / Male Mobile : 9897623527
Ref. By : Dr. Dr. Vikash Sirohi Receipt No. :
Reg. No : DEL010.00000143 Date&Time : 23-Sep-2021 09:45 AM

SNo Test Department Specimen Type

BIO101~GLUCOSE, FASTING ( GLUCOSE, BIOCHEMISTRY

1 PLASMA
FASTING )
BIO116~HBA1C; GLYCOSYLATED BIOCHEMISTRY
2 HEMOGLOBIN ( HBA1C; GLYCOSYLATED WHOLE BLOOD
HEMOGLOBIN )
BIO188~LIPID PROFILE (7 PARAMETERS) BIOCHEMISTRY
3 SERUM
( LIPID PROFILE (7 PARAMETERS) )
BIO181~RENAL PROFILE (6 BIOCHEMISTRY
4 PARAMETERS) ( RENAL PROFILE (6 SERUM
PARAMETERS) )
BIO206~EGFR - ESTIMATED BIOCHEMISTRY
GLOMERULAR FILTRATION RATE ( EGFR -
5 SERUM
ESTIMATED GLOMERULAR FILTRATION
RATE )
BIO182~LIVER FUNCTION TEST (11 BIOCHEMISTRY
6 PARAMETERS) ( LIVER FUNCTION TEST SERUM
(11 PARAMETERS) )
7 BIO186~IRON PROFILE ( IRON PROFILE ) BIOCHEMISTRY SERUM
CLP183~COMPLETE URINE EXAMINATION CLINICAL PATHOLOGY
8 URINE
( COMPLETE URINE EXAMINATION )
HEM179~COMPLETE BLOOD COUNT HEMATOLOGY
9 (CBC) ( COMPLETE BLOOD COUNT (CBC) WHOLE BLOOD
)
HEM151~PERIPHERAL SMEAR ( HEMATOLOGY
10 WHOLE BLOOD
PERIPHERAL SMEAR )
IMM184~THYROID PROFILE (TOTAL T3, IMMUNOLOGY
11 TOTAL T4, TSH) ( THYROID PROFILE SERUM
(TOTAL T3, TOTAL T4, TSH) )
IMM172~VITAMIN D (25 OH )-TOTAL ( IMMUNOLOGY
12 SERUM
VITAMIN D (25 OH )-TOTAL )
13 IMM176~VITAMIN B12 ( VITAMIN B12 ) IMMUNOLOGY SERUM

PACK192~COMPREHENSIVE FULL BODY CHECKUP WITH VITAMIN D & B12,HEM179~COMPLETE BLOOD

COUNT (CBC),HEM151~PERIPHERAL SMEAR,BIO101~GLUCOSE, FASTING,BIO116~HBA1C;
GLYCOSYLATED HEMOGLOBIN,BIO188~LIPID PROFILE (7 PARAMETERS),BIO181~RENAL PROFILE (6
PARAMETERS),BIO206~EGFR - ESTIMATED GLOMERULAR FILTRATION RATE,BIO182~LIVER FUNCTION
TEST (11 PARAMETERS),BIO186~IRON PROFILE,IMM184~THYROID PROFILE (TOTAL T3, TOTAL T4,
TSH),IMM172~VITAMIN D (25 OH )-TOTAL,IMM176~VITAMIN B12 ,CLP183~COMPLETE URINE
EXAMINATION

Sample Collection Time:

Sample Receiving Time:
Remarks/Clinical Information:

Created By : Dr. Bhatnagar Diagnostic Center Printed By : Dr. Bhatnagar Diagnostic Center Print
DateTime: 23/09/2021 9:46 AM