NATIONAL REFERENCE LABORATORY for

HIV/AIDS, Hepatitis B/C & Other STIs LABORATORY REQUEST FORM

San Lazaro Hospital Date Requested ( MM/DD/YYYY ):
STD AIDS Cooperative Central Laboratory
Quiricada St., Sta. Cruz, Manila
Tel Nos:(+632)3109528 to 29 Laboratory Number:
Fax No: (+632)711-4117
Email: [email protected]
website: nrlslhsaccl.com.ph
In-Patient ________________________________________

Out-patient _________________________________________
Last name

PATIENT INFORMATION
Last Name: First Name: Middle Name:
( ) ( ) ()

Patient Code: Date of Birth: Marital status: Gender: Age:

(MM/DD/YYYY) [ ] Single [ ] Married [ ] Male
( ) [ ] Widowed [ ] Separated [ ] Female

Address: Telephone No./ Mobile No.:

LABORATORY TESTS
Name and Signature of Referring Physician  HIV Screening
 HBsAg
Clinical Diagnosis
 HBeAg/Anti-HBe
FOR SACCL USE ONLY  Anti-HBc IgM
 Anti-HBc Total
Date and Time Specimen Collected:
 Anti-HBs
 Anti-HCV
Specimen Collected by( Signature over Printed Name ):
 RPR
 TPHA
COLLECTION TUBE SPECIMEN  TPPA
 HBV Viral Load
Red Yellow Serum Whole Blood
 HIV Viral Load
Lavender Others Plasma Urine Others
 Chlamydia PCR
TEST RESULTS RELEASE  Gonorrhea PCR
Pick up Mail  Gram Stain (STI)
 GC Culture/Sensitivity
Bill To: Test Amount: ________ OR#: _______________  Wet Mount
Patient Discount: ________  KOH
Philhealth Total Amount Paid: _____________  Others _____________________
FOC ___________________________

Receiving Officer: ___________________________

Signature over Printed Name

LAB-F-313, Effectivity Date: May 12, 2014, Issue 1, Rev. 2

----------------------------------------------------------------------------------------------

CLAIM STUB
NAME: ___________________________ Referring Agency: ___________________________ DATE: __________
LAB TEST/S DONE: _______________________________________________________________________________
DATE OF RELEASE:________________________________________________________________________________
ID PRESENTED: ___________________________________________________________________________________
(Government issued/Company ID)
_____________________ _____________________
Receiving Officer Releasing Officer
Signature Over Printer Name Signature Over Printer Name
LAB-F-313, Effectivity Date: May 9, 2014, Issue 1, Rev. 2