Lab Request Lab Request Form LABOARATORY REQUEST FORM Laboratory Use Only Fasting Non-Fasting Random 24 Hour Sample Type Blood Faeces Urine CSF Fluid Swab Sputum Other Anatomical Site: Priority Urgent Routine High Risk Yes No Specimen Date Requesting Clinician Name Requesting Clinician email Phone Requesting Clinician GMC Number Patient Details Name of Patient Name of Patient First First Last Last Date of Birth * Email Relevant clinical details Relevant medicines Time of last dose (if relevant) Profiles Biochemistry (Bio) Bio/HDL Haem/Bio Haematology (Haem) Haem/Bio (Short) LFT 1 LFT 2 (Extended) Bone profile (Inc Urines) Bone profile 1 Lipid profile Cardiovascular Risk Profile Cardiovascular Risk Profile Plus Well Person Screen 1 (Haem/Bio, T4, TSH, Ferritin) Well Person Screen 2 (Haem/Bio/HDL, T4, TSH, Ferritin) Well Man Screen (Haem/Bio/HDL, T4, TSH, PSA Ferritin)” Well Person Screen 1 plus VITD Well Person Screen 2 plus VITD Senior Male Profile 60+ Senior Female Profile 60+ Sexual Health Profile (7STI PCR Screen) Cardiac Chest Pain D-Dimer NT-pro BNP Hormones Thyroid Profile 1 Thyroid Profile 2 Thyroid Profile 3 Male Hormone Profile Erectile Dysfunction Prolactin Testosterone SHBG Female Hormone Profile Anti Mullerian Hormone Menopausal Profile Amenorrhea Profile Polycystic Ovarian Syndrome Faeces Calprotectin QFIT Amylase Other Common Test Amylase Random Blood Glucose HbA1C (Glycosylated Hb) Vitamin D (25 OH) Vitamin B2 Vitamin B6 Vitamin B12 24Hr Urine Creatinine Clearance Calcium Seratonin 5H1AA Catecholamines Metanephrines Oxalate Phosphate VMA Haematology Full Blood Count (5-Part Diff) Blood Film Malarial Parasite Film Reticulocytes Sickle Screen (Hb-solubility) Hb Electrophoresis Prothrombin Time/INR Coag Profile (PT, APTT, FIB) Thrombotic Risk Profile Anaemia Ferritin B12 & Red Call Folate Serum Folate Iron Status Profile Factor V Leiden (Mutation) ” Mineral Profile (Cal, Mg, Zn, Fe, Cu, Chrm, Mgn)” MC&S MSU (Microscopy & Culture) Stool OCP/Culture Sputum Sputum TB (AFB) Fluid Fluid Crystals Wound Swab MRSA 1 Specify No of Swabs” Ear Swab Throat Swab High Vaginal Swab (HVS) Other Swab Allergies UK Allergy Profile Food & Inhalents Inhalents Food Immunology & Rheumatology Gluten Sensitivity Coeliac Disease Profile Gluten Allergy Profile Autoantibody Profile 1 Autoantibody Profile 1 RH (Haem, UA, RF, ACCP, CRP) RH2 (Connective Tissue) RH3 (Rhematoid Disease) RH4 (SLE) Immunology & Rheumatology Gluten Sensitivity Coeliac Disease Profile Gluten Allergy Profile Genetics ASHJ (Jewish Carrier) GENE (Pan Ethnic Carrier) GRP (Genetic Repro Profile Male) RMP (Recur Misc Profile-Female PROP (Thrombotic rick Profile DVT1 (DVT/Pre travel Screen) IOP (Iron Overlaod Profile) Infection Paul Bunell / IM C-Reactive Protein SARS-CoV-2 PCR (NCOV) Needle Stick Injury (STDX) (HIV, HBV, HCV, PCR Day 10 PO) Needle Stick Save Serum Hepatitis HAVM, HBsAg, HCVcAb, HCVcAg” HIV (HIV I/II) Hep ABC (HEPA, HBsAg, HBsAb, HBcAg HCVcAb, HCVcAg) Hep B (Core AbIgm) HBC (Hep B Core AbIgm to Core Ab IgM STD2 (HIVI/II, HbsAg, HCVcAB, HCVcAg, Syp, CT, NG, MG, TV, GV) Ureaplasma HS I/II by PCR)” STD4 (HIVI/II, HbsAg, HCVcAB, HCVcAg, Syp, CT, NG, MG, TV, GV) Ureaplasma HS I/II by PCR)” Tumor Markers CA 125 (Ovarian) CA 15.3 (Breast) CA 19.9 (Pancriatic) CEA Prostate Profile AFP Beta-HCG Signature Clear Date Role If you are human, leave this field blank. Submit
