Click here to download the Antenatal Request Form
- Patient Details
- Please refer to this section under General Request Form for details.
- Please provide the additional information for:
- Race
- Weight (kg)
- Referring Doctor’s Name, Address & Doctor’s Code
Please stamp the clinic chop under this section along with the Doctor’s name. Samples without the doctor’s name and clinic chop will be rejected.
- Urgent
The phone / facsimile number should be written clearly for our laboratory staff to report the results immediately once the test(s) has been completed.
- Copy to
Please refer to this section under General Request Form for details.
- Bill to
Please refer to this section under General Request Form for details.
- Specimen Requirement
Please fill in date sample was collected from patient.
- Pregnancy Details
Please indicate if this is a single / twin pregnancy.
- Recommended Timing is 14 to 19 Weeks Gestation (Gestational Details)
Please fill in gestational details in weeks and days according to either
- Ultrasound (indicate date of ultrasound)
- Clinical Assessment
- LMP (indicate date of LMP and indicate if certain of date or not)
- Clinical History
Please provide clinical history such as reason for test and EDD. Kindly sign and date the request form
