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Lancet Laboratories

LANCET CLIENT HELP DESK

TEL:	+27 11 358-0768 / 358-0858
FAX:	+27 11 242-7130
Email:	client@lancet.co.za

HELP DESK NUMBER: 0800 110 292

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URGENT ROUTINE FASTING RANDOM

REFERRING DOCTOR
HOSPITAL & WARD		FILE NO / HOSPITAL NO
COLLECTION DATE	COLLECTION TIME	VENESECTIONIST

PATIENT DETAILS

SURNAME		FIRST NAME		TITLE		SEX
ID NUMBER		DATE OF BIRTH [YYYYMMDD]		AGE		PATIENT TEL

I GIVE CONSENT FOR TESTS, RELEASE OF DIAGNOSTIC ICD10 CODES TO MY MEDICAL AID AND GUARANTEE PAYMENT OF ANY OUTSTANDING AMOUNTS NOT COVERED BY MEDICAL AID OR EXCEEDING THE ESTIMATE QUOTE.

CLINICAL INFORMATION

SPECIMENS TAKEN

REC. BY:
DATE:			TIME:
		TAKEN	REC	DEPT.
ACD	A
HEPARIN	H
CITRATE	C
EDTA	E
CLOTTED	B
CLOT (No SST)	BP
FLOURIDE	FL
URINE	U
SWAB	S
FAECES	F
OTHER

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HELP DESK NUMBER: 0800 110 292

CLINICAL INFORMATION

TAKEN

REC

DEPT.