DEPARTMENT OF LABORATORY

REQUEST FOR CYTOLOGY CONSULTATION

Health Record No.:__________________ Specimen No. ___________________

Date & Time Received: ______/______/______ ____:____ AM/PM

Please print name legibly and fill-in all the blanks.

Last name:

First name:

Middle name:

Age: ______ Sex:______ Ward:______ Service:_________ Date of Birth:______/______/______

Request for: [ ] Papanicolau Smear [ ] Routine Cytology

Specimen:________________________________________________________________________

Procedure:_______________________________________________________________________

Last Menstrual Period (LMP), if applicable:______________________________

Pertinent Clinical Data:

_________________________________________________________________________________
_________________________________________________________________________________

Clinical Diagnosis: ________________________________________________________________

Requesting Physician:___________________________________ Date:______/_______/_______

Relative’s Data:
Name: _______________________________________
Signature: ____________________________________
Contact No:___________________________________