LANCET ELECTRONIC REQUEST FORM

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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NOVO IMMOGENICS

TEL: FAX:

URGENT! Please call an Urgent courier, Sample needs to be at Richmond Laboratory by 13H00.

REFERRING DOCTOR	00IMMO		COPY DOCTOR
			FILE NO / HOSPITAL NO
COLLECTION DATE		COLLECTION TIME	VENESECTIONIST

PATIENT DETAILS

REFERENCE NUMBER: ZW\\

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.

OFFICE INFO:

ICD10 CODES

CLINICAL INFORMATION

OTHER TESTS

SPECIMENS TAKEN

REC. BY:
DATE:		TIME:
	TAKEN	REC	DEPT.
ACD 8.5ml TUBE

HELP DESK NUMBER: 0800 110 292

ICD10 CODES

CLINICAL INFORMATION

OTHER TESTS

TAKEN

REC

DEPT.