Gribbles Pathology Malaysia

Click here to view/download the General Request Form

A. Patient Details

• Please fill in the patient’s name in the space provided in BLOCK letters
• Please fill in the patient’s IC/Passport No, Date of Birth, Sex and if there is a reference no. you would like to be on the report, please fill in the space under Your Ref. 
• Patient’s address is not required as we will only send the report directly to your clinic.

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.

C. Urgent

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.

F. Cash

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

• Please indicate whether the patient has been fasting / not before the test
• Please indicate the sample type by checking the relevant box on the form or if it is other than the choices available, please write it under Others

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

• Please write the name of the test(s) that are not listed on the form.
• Kindly initial under Doctor’s Signature
• Kindly date the Request form