Download General Practitioners Request for Laboratory Services

GP Request for Laboratory Services MICROBIOLOGY DEPARTMENT
Central Pathology Laboratory, St. James’s Hospital, Dublin 8.
Tel.: 4162941 / 4162966 / 4162967
Patients attending the Phlebotomy Clinic for Blood Tests should go to “Route 2” from the main
hospital reception. Opening Hours: 07.30 – 12.00 Monday to Thursday (except Public Holidays)
FOR LABORATORY USE
ONLY
PLEASE AFFIX SPECIMEN
NUMBER BARCODE
LABELHERE
Patient Details (Complete Fully OR Attach an Addressograph Label inside the dotted line below):
Surname
First Name
Date of Birth
Male
/
/
Female
Ethnicity (if relevant)
Patient’s Address:
Doctor’s
Name
Doctor’s
SJH Lab Code
Doctor’s
Signature
Medical Council
Registration Number
Clinical
Details
Practice address or practice stamp here
Practice Telephone Number:
This is mandatory to ensure the
doctor can be contacted during
routine laboratory working
hours 8am to 8pm.
Drug / Antibiotic
Therapy
SPECIMENS (Please Tick): Blood
Urine
Stool
Swab
Other
Tests Required (Please Tick Below)
General Microbiology
[
] Urine C/S
Fungal Culture
STI Molecular Investigations
[
] Swab
[ ] Nail Clippings
[ ]CT/NG (First Void Urine)
Site:
[ ] Skin Scrapings
[ ]CT/NG (Endocervical Swab)
[ ] Hair
[ ]CT/NG (Pharyngeal)
[ ] Sputum C/S
[ ] Sputum TB
[ ]CT/NG (Rectal)
[ ] Stools Investigation
[ ] Stools OP**
[ ] Herpes Simplex Virus
** These investigations will
[ ] MRSA Screen
only be performed if relevant
(Nasal / Throat / Groin)
Specify:
clinical details are provided.
Serology (Order either profiles or individual Investigations as appropriate)
For further information please refer to “Viral Hepatitis Testing for General Practitioners” in the
Laboratory Policies & Guidelines section at www.stjames.ie under the Lab Services tab.
[ ] Fluid C/S
PROFILES
INDIVIDUAL INVESTIGATIONS
[ ] STI Screen Syphilis / HIV / HepBsAg
[ ] Measles / Mumps / Rubella Screen IgG
[ ] Syphilis
[ ] Measles
[ ] HIV
[ ] Mumps
[ ] HepBsAg
[ ] Rubella
[ ] Hep C Ab
[ ] Hep BsAb
[ ] Viral Hepatitis B&C Screen (HepBsAg / Hep C Ab)
[ ] Hep BcAb
[ ] Hepatitis B Infection Status (HepBsAg / HepBcAb)
[ ] Hep C core Ag
[ ] Hep A IgG
[ ] Current Hepatitis C infection (HCV Ag)
[ ] Hep C RNA PCR
[ ] VZV IgG
(Post-Vaccination)
[ ] Other
Date Taken:
Time Taken:
Date/Time Received:
Specimen requirements and other information is available on www.stjames.ie by clicking on the “Lab Services” Tab.
P904B Version 3