EMEGEN Diagnostics – Laboratory/Imaging Request Form

EMEGEN
Diagnostics

Precise Insights, Treasured Help

Laboratory / Imaging Request Form

ISO 15189 Standard

Adabraka
Owegon Ave | GA-102-4130
+233 24 101 7059

Nima
Okutu Street | GV-025-2083
+233 24 101 6132

[email protected]

Patient Information

Patient Name

Facility

Phone

Age / DOB

Clinician

Address

Sex

ID / File No.

Diagnosis

SPECIMEN TYPE:

Blood Urine Others:

Haematology

EDTA – Purple Westergren – Black Citrate – Blue

Clinical Chemistry

Fluoride/Swab – Grey SST – Gold Heparin – Green EDTA – Purple Plain – Red

Microbiology & Parasitology

BACTEC – Gold Swab – Grey Urine/Stool container EDTA – Purple ⚠ NOTE: All Holders Must Be Sterile

Serology / Molecular

SST – Gold Plain – Red EDTA – Purple

Ultrasound / Imaging

Obstetric Abdominal Pelvic Abdominopelvic Prostate Doppler

Others:

For Facility Use Only

Received By

Time

Priority

Urgent Routine

Facility / Lab Email

CC (optional)

✉ Open in Mail App