Guidelines on Forms

Patient Details

• Please fill in the patients name in the space provided in BLOCK letters
• Please fill in the patients IC/Passport No, Date of Birth, Gender and there is a reference no. you would like to be on the report, please fill in the space under “Your Ref”

Referring Doctor’s Name, Address & Clinic Stamp

There are 2 types of general request forms:

1. Pre-printed request forms
2. Standard request forms

If you are using standard request forms, please ensure you stamp the clinic chop under this section along with the Doctor’s name. Reports cannot be issued if the name of the doctor and clinic chop is not on the request form

Urgent
Please indicate if the results for this test(s) are needed urgently by ticking the URGENT box and placing the sample in an URGENT specimen carrier bag. The phone /facsimile number should be written clearly for our laboratory staff to report the results immediately once the test(s) has been completed. If the urgent box is not ticked the specimen will follow the routine que.

Copy To
Reports are delivered automatically to the Referring Doctor’s clinic address. If the reports needs to be delivered to an alternate/ additional address from the Referring Doctor’s, please indicate it in this space.

Bill To
This is for use where the bill is to go to a third party

Specimen Type
Please indicate the sample type by ticking the relevant box on the form or if it is other than the choices available, please write exactly what it is under “Others”.

Specimen Taken From Patient
Please write the date and time specimen was taken from the patients for proper results evaluation. Please indicate whether the patient has been fasting/not fasting before the test.

Drug Therapy
If the patient is under medication that could influence his/her test results, please indicate the drug name and the date & time of the last dosage. Please indicate the name of the antibiotic(s) taken if culture specimens are obtained after anti-microbial therapy has been started.

Clinical History

• Clinical diagnosis
• Suspected disease / organism
• Medication that could influence his/her test results (indicate drug name and the date and time of last dosage)
• Brief clinical history
• Name, date & duration of antibiotic(s) administered (especially if culture testing is required)
• Any previous culture or serological test results
• Immune status of patient e.g.: underlying diseases, cancer chemotherapy, and immunosuppressive treatment.

For Bone Marrow and Trephine Biopsy, please provide:

• Clinical history, provisional diagnosis, significant physical findings
• Site of bone marrow specimen
• Recent FBC results or EDTA blood sample
• Peripheral blood film or EDTA blood sample

Test Required
Please tick the relevant test.

Additional Tests
For tests that are not listed on the request form, kindly write it under the blank column provided at the end of the form.

II. Prenatal Diagnosis Request Form

For Prenatal Diagnosis the additional information required for you fill, apart from what was explained under General Request Form is explained below:

Race and weight (kg)
Pregnancy details, please indicate if this is a single / twin pregnancy
Gestational Details & Timing Requirements for Sampling

For both 1st Trimester and 2nd Trimester screens, please fill in the following gestational details in weeks and days according to either:

• Dates (indicate date of LMP, EDD and if certain of date or not)
• Ultrasound (indicate date of ultrasound) – REQUIRED for 1st Trimester screen.

For 1st Trimester screen only, please fill in CRL and NT length and date of measurement. Also please attach ultrasound report of Nuchal Translucency measurement with this form. Please note the details regarding certification requirements of the Ultra sonographer on the form.

III. Histology & Cytology Request Form

For Histology and Cytology the additional information required for you to fill apart from what was explained under General Request Form are explained below:

1. For cytology test, please provide the following additional information:
   • Menstrual status (LMP/pregnant/post-partum, post-menopausal).
   • Origin (site) of sample (cervix, vault, etc).
   • History of hormone therapy (OCP/hormones/HRT) and IUCD.
   • Status of cervix: Normal, erosion, discharge, suspicious, etc.
   • History of gynecological surgery or radiation therapy - Yes/No.
   • The name, signature, contact details of doctor/smear taker and date of smear taken must be stated on the request form.
2. For histology Test, please provide the following additional information:
   • Relevant clinical history including operative findings (where relevant) and provisional diagnosis (where possible).
   • Type of sample and anatomical site must be stated.
   • Name and contact details of physician/surgeon in charge of case
   • Date of previous biopsy operation