OVI Children's Hospital
Laboratory Request and Report Form
Patient Details
Name
Age
Sex
M
F
Resident/Village
Report to (Specify Clinical/Ward/Clinician)
Specimen Details
Specimen Type
Collection Date/Time
Specimen No.
Specimen Destination
Tick appropriate box
Blood Bank
Histology/Cytology
Serology
Haematology
Bacteriology
Parasitology
Biochemistry
Other
Blood Group
Hb
Investigation and Diagnosis
Investigation Requested
Differential Diagnosis
Requesting Clinician
Name
Date
Signature
Submit Lab Request