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    Gene Xpert Form

    Uploaded by

    Aina Haravata
    This document is a laboratory request form used to request tuberculosis (TB) tests. It collects information such as the patient's name, age, sex, address, treatment history, disease classification, reason for examination, type of specimen collected, and tests requested. The form is filled out by the health worker collecting the specimen and includes details like the name of the collecting unit, requesting physician, specimen collector, and their designations.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Gene Xpert Form

    Uploaded by

    Aina Haravata
    74 views1 page
    This document is a laboratory request form used to request tuberculosis (TB) tests. It collects information such as the patient's name, age, sex, address, treatment history, disease classification, reason for examination, type of specimen collected, and tests requested. The form is filled out by the health worker collecting the specimen and includes details like the name of the collecting unit, requesting physician, specimen collector, and their designations.

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    This document is a laboratory request form used to request tuberculosis (TB) tests. It collects information such as the patient's name, age, sex, address, treatment history, disease classification, reason for examination, type of specimen collected, and tests requested. The form is filled out by the health worker collecting the specimen and includes details like the name of the collecting unit, requesting physician, specimen collector, and their designations.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    74 views1 page

    Gene Xpert Form

    Uploaded by

    Aina Haravata
    This document is a laboratory request form used to request tuberculosis (TB) tests. It collects information such as the patient's name, age, sex, address, treatment history, disease classification, reason for examination, type of specimen collected, and tests requested. The form is filled out by the health worker collecting the specimen and includes details like the name of the collecting unit, requesting physician, specimen collector, and their designations.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    Form 2a.

    NTP Laboratory Request Form

    To be filled out by Health Worker

    Name of Collection Unit: ___________________________________ Date of Request: ____________

    Name of Requesting Physician: ______________________________

    Name of Patient: ____________________________________ Age:_____ Sex: M F

    Address (in full):_____________________________________Tel./Cellphone no.________________

    History of Treatment: New Re-treatment Relapse Treatment after Failure

    TALF PTOU

    Transfer in Others

    Disease Classification: Pulmonary Extra-Pulmonary Site: _________________

    Reason for Examination: Diagnosis Follow-up, TB case No.:________________

    State if repeat collection and reasons: ________________________________________________

    Type of Specimen: Sputum Other (Specify)

    Test requested: DSSM Culture LPA

    Xpert MTB/RIF DST

    Specimen Date of Collection

    Name of Specimen Collector: ______________________________

    Designation of Specimen Collector: _________________________

    Portion below to be filled out by Medical Technologist or Microscopist

    Laboratory Serial No. _____________ Date Received: ___________________

    Smear Microscopy Xpert MTB/RIF


    SPECIMEN
    Visual Appearance
    Reading
    Lab. Diagnosis

    Date of Examination:________________________ Examined by:___________________________


    (Signature over printed name)

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