PATHOLOGY REQUEST MEDICARE CARD NUMBER

PATIENT SURNAME GIVEN NAMES SEX DATE OF BIRTH YOUR REF:

Arevalo Rubio Mary Sandra F 20/05/1974

PATIENT ADDRESS
TEL TEL (BUS)
M: 0412698475
60 Binalong Ave
H:
Allambie Heights, NSW, 2100, AU

TESTS REQUESTED Fasting

Non-Fasting
Pregnant
Hormone
Urine chlamydia,gonnorhoea, mycoplasma genitalium PCR NAAT, HIV,SYPHILIS, HEPATITIS B/C Therapy
SEROLOGY LNMP
EDC
Cervical
CLINICAL NOTES Cytology
Site Cervix
Vaginal
STI SCREENING
Vault
Site:
Endometrium
Other
DOCTOR SIGNATURE Post Natal
Post
URGE REQUEST Menopausal
PHONE FAX BY TIME: DATE
NT Radio Therapy
PHONE/FAX No: / IUCD
25/08/2024 Abnormal
PRIVA CONCESSI BULK
TE ON BILL Bleeding
Cervix Benign
VET AFFAIRS No: Cervix
Suspicious

REQUESTING DOCTOR COLLECTION

COPY REPORTS TO Dr Senan Al-Saffar CENTRE USE
Doctors on Demand
Level 2, 39 Grey Street
South Brisbane, QLD 4101
Ph: 0736389377
HOSPITAL/WARD Fax: 0731034665
511933BH

PATIENT STATUS AT TIME OF SERVICE OR WHEN SPECIMEN MEDICARE ASSIGNMENT (Sector 20A of the Health insurance Act 1973) PATIENT'S SIGNATURE AND DATE
COLLECTED I assign my right to benefits to the approved practitioner who will render the requested
Yes No pathology service(s).
1. Private patient in a private hospital or approved day hospital
facility
PRACTITIONER'S USE ONLY
2. Private patient in a recognised hospital (Reason Patient cannot sign)
3. a Medicare (public) patient in a recognised hospital ACC SPECIMENS::
COLLECTOR TO COMPLETE:
4. Outpatient of recognised hospital I certify that the blood specimen F NF
accompanying this request was drawn NAME:
PRIVATE BULK BILL
from the patient stated as established
by direct enquiry of the patient and/or SIGN: TOLM:
This document is issued in inspection of the ID wrist-band and that
accordance with NATA/RCPA specimen was labelled immediately.
accreditation requirements. Accredited I have also signed the sample tube(s) TIME: DATE: TOLD:
Lab Number

PATIENT'S SIGNATURE AND

PATIENT STATUS AT TIME OF SERVICE OR WHEN SPECIMEN
COLLECTED MEDICARE ASSIGNMENT DATE
Yes No
1. Private patient in a private hospital or approved day hospital (Sector 20A of the Health insurance Act 1973)
facility
2. Private patient in a recognised hospital
3. a Medicare (public) patient in a recognised hospital I assign my right to benefits to the approved
4. Outpatient of recognised hospital practitioner who will render the requested
PRIVATE BULK BILL pathology service(s).