Click here to view/download the General Request Form
A. Patient Details
B. Referring Doctor’s Name, Address & Doctor’s Code
There are 2 types of general request forms: Pre-print and non pre-print request forms. We will print forms for your clinic FOC and the use of pre-printed forms is encouraged as it reduces the frequency of data entry errors. If you are using the non pre-print request forms, please ensure you stamp the clinic chop under this section along with the Doctor’s name. Samples will be rejected if the name of the doctor and clinic chop is not on the request form.
Please indicate if the result for this test(s) is needed urgently by checking the URGENT box. The phone / facsimile number should be written clearly for our laboratory staff to report the results immediately once the test(s) has been completed.
D. Copy to
Reports are delivered automatically to the Referring Doctor’s clinic address. If the report needs to be delivered to an alternate/additional address from the Referring Doctor’s, please indicate it in this column.
E. Bill to
Refers to the account payer’s billing code. Billing Code will be printed here if it is on a pre-print request form.
Please check this box if you are paying with cash. Kindly ensure the Amount, Receipt No and Collected By details have been filled. This is for our records and should there rise any situations of missing cash, we would be able to investigate thoroughly with such information.
G. Specimen Type
H. Specimen Taken from Patient
Please write the date and time specimen was taken from the patient for proper test results evaluation.
I. Drug Therapy
If the patient is under medication that could influence his / her test results, please indicate the drug name and the date & time of the last dosage. Please indicate the name of antibiotic(s) taken if culture specimens are obtained after anti-microbial therapy has been started.
J. Cervical Cytology
Please indicate the test(s) requested by checking the test boxes. Please check and fill the clinical information required e.g. site of sample collection, patient condition, LMP etc.
K. Clinical History
Details such as below should be written in this section to assist with test results evaluation:
- Clinical diagnosis
- Suspected disease / organism
- Brief clinical history
- Name, date & duration of antibiotic(s) administered (if not already indicated under Drug Therapy)
- Any previous culture or serological test results
- Immune status of patient e.g. underlying diseases, cancer chemotherapy, immunosuppressive treatment
For Cytology tests, please provide following additional information:
- LMP (please indicate this under Cervical Cytology)
- Hormonal status e.g. post-menopausal, gravid (please indicate this under Cervical Cytology)
- Exogenous hormone therapy incl. birth control pills, treatment for endocrine-responsive malignancy, estrogen creams etc
- Usage of intrauterine device (IUCD)
- Exposure to diethylstilbesterol (DES)
- History of abnormal cytology / gynaecology disorders
- Date of last gynaecological smear, if any
For Histopathology tests, please provide following additional information:
- Summary of clinical history
- Operative findings
- Type of sample and anatomical site (please indicate this under Anatomical Pathology)
- Provisional diagnosis
- Date of previous biopsy operation
For Bone Marrow and Trephine Biopsy, please provide:
- Clinical history, provisional diagnosis, significant physical findings
- Site of bone marrow specimen
- Recent FBC results or EDTA blood sample
- Peripheral blood film or EDTA blood sample
L. Profile Test, Biochemistry, Haematology, Microbiology, Anatomical Pathology & Cervical Cytology
Please check the relevant test box / boxes. Kindly fill in clinical information required under Anatomical Pathology and Cervical Cytology.
M. Additional Tests
Copyright © 2007 - 2021 Gribbles Pathology (M) Sdn Bhd. All Rights Reserved.
Powered by CORNERSTONE CONTENT MANAGEMENT SYSTEM