Below are our request forms. If you can’t find the form you need or are insure of which form to use please call 020 8266 6510 (between hours of 8am to 8pm).
These forms can also be used if you are unable to submit a request electronically – for example if there is pathology systems downtime.
Forms
- Biochemistry, haematology and immunology request form
- Epsom and St Helier biochemistry and haematology request form
- Diagnostic cytology request form
- Histology request form
- Microbiology request form
- Microbiology LTBI test request form
- Molecular pathology request form
- Placental form – St George’s Hospital
- Placental form – Kingston Hospital
- Prostate request form
Patient details
Each request form must contain the following patient identification criteria:
- the patient’s NHS or Medical Record Number
- the patient’s family and given names
- the patient’s date of birth.
Clinical reporting
It is necessary to interpret the results and display the appropriate reference range of the tests
- Date and time the specimen was collected
- The gender of the patient
Pre-printed labels
Pre-printed labels may be used to provide the patient details provided they are attached as indicated on the form itself.
Tests
Tick the appropriate tests on the form or print clearly any additional ones that are not included.
Exceptions
Requests from patients whose identity is incomplete will only be accepted, if they fall into the following categories:
- Unknown patients attending A&E. These will be identified using agreed, local rules.
- Forms requesting either Histology or Diagnostic Cytology investigations should include the full name of the consultant together with their GMC number. This will overcome any confusion regarding the identity of the requestor.
- New born babies without a Given name can be identified as Baby Smith for instance, but must have a MRN number and date of birth.
- Twins without Given names can be identified using Twin 1, Smith and Twin 2, Smith. Again the MRN number and date of birth must be provided.
- Specimens from patients attending the GU Medicine clinic need not display all of the Core Identifiers, but only show a unique patient number and the patient’s Date of Birth.
- HMP patient requests, only display the patient’s DOB and surname
- Private patients not having an NHS or MRN number. The request should clearly show they are a private patient. The first line of the patient’s address should be included on the request form and written on all specimen containers.
Antenatal screening requests
For requests made as part of the Antenatal Screening Programme, if the individual’s NHS or MRN number is not known their address must be used as the third identifier. In these cases, the first line of the address must also appear on the specimen container.
