laboratory request form - Research Institute for Tropical Medicine

RESEACH INSTITUTE FOR TROPICAL MEDICINE
Laboratory Research Division
Filinvest Corporate City, Alabang, Muntilupa City, 1781
Tel. Nos.: (02) 807-2628 to 32
LABORATORY REQUEST FORM
Note: All specimens should be accompanied by a legibly and completely filled out Request Form. Use Block Letters.
Patient’s Name (Family, First, MI): Sex: Age (yrs./mos.): Date of Birth
(mm/dd/yy):
Complete Address:
Clinical Impression:
Requesting
Physician:
Date of Onset
Hospital:
(mm/dd/yy):
Suspected Infectious
Agent:
Address:
Telephone No.:
Facsimile No.:
MICROBIOLOGY LABORATORY:
Test Types: Culture & Susceptibility (CS); Nucleic Acid Amplification Test (NAAT); Serology (S); Rapid Antigen
Detection (RAD)
Date received
(mm/dd/yy):
Diseases
1. Acute Bloody Diarrhea
2. Typhoid and Paratyphoid Fever
3. Cholera
4. Anthrax
5. Leptospirosis
6. Meningococcal Disease
7. Diphtheria
8. Pertussis
9. Bacterial Meningitis
10. Others: ________________________
Time received
(hh:mm):
Test
Type
Specimen
Type
Received
by:
Date & Time
Collection
(mm/dd/yy)
(hh:mm)
Lab ID
(For
RITM
Use)
PARASITOLOGY LABORATORY:
Test Types: Microscopy (CS); Nucleic Acid Amplification Test (NAAT)
Date received
Time received
(mm/dd/yy):
(hh:mm):
Diseases
1. Malaria
2. Diarrheal Disease due to Parasites
3. Others: ________________________
Test
Type
Specimen
Type
Received
by:
Date & Time
Collection
(mm/dd/yy)
(hh:mm)
Lab ID
(For
RITM
Use)
Version 2011-05-04 DAlmonia

VIROLOGY LABORATORY:
Test Types: Viral Culture (VC); Nucleic Acid Amplification Test (NAAT); Rapid Antigen Detection (IF);
Viral Serology (VS)
Date received
(mm/dd/yy):
Diseases
1. Acute Encephalitis Syndrome (AES)
2. Acute Flaccid Paralysis Syndrome
3. Acute Hemorrhagic Syndrome
4. Dengue
5. Human Avian Influenza
6. Influenza – like Illness
7. Measles
8. Others: _____________________
Time received
(hh:mm):
Test
Type
Specimen
Type
SPECIAL PATHOGEN LABORATORY:
Test Types: Antigen Detection Test (ADT); Nucleic Acid Amplification Test (NAAT)
Date received
(mm/dd/yy):
Time received
(hh:mm):
Received
by:
Diseases
1. Ebola Reston
2. Rabies
3. SARS
4. Emerging Zoonotic Disease
5. Newly Identified Pathogen (Respiratory
Illness)
6. Unidentified Pathogen
7. Others: ____________________
Test
Type
Specimen
Type
Received
by:
Date & Time
Collection
(mm/dd/yy)
(hh:mm)
Date & Time
Collection
(mm/dd/yy)
(hh:mm)
Lab ID
(For
RITM
Use)
Lab
ID
(For
RITM
Use)
IMMUNOLOGY LABORATORY:
Test Types: Serology (S)
Date received
(mm/dd/yy):
Diseases
1. Hepatitis A virus
2. Others: _________________
Time received
(hh:mm):
Test
Type
Specimen
Type
Received
by:
Date & Time
Collection
(mm/dd/yy)
(hh:mm)
Lab
ID
(For
RITM
Use)
Version 2011-05-04 DAlmonia