R R1059 TSH (cord blood) C

G T1058 TSHC

G W1060 FREE T4C

G A1061 FREE T3C

G L1077 PROGESTERONEC

G L1951 TESTOSTERONE (FAI)C

G K1079 DHEA-SC

G K3655 ANTI-MULLERIAN HORMONE (AMH)C

G J1094 AFPC

G Z1486 b-HCG tumour marker (male / female)C

G B1092 OV 125 (ovary) C

G N1093 BR15.3 (breast)C

G D1090 CEA (G.I.T., lung, breast)C

G L1031 PROT ELECTROPHORESIS C

G X1022 ALP C

GU¯ Q1005 CREATININE CLEARANCE C

P Y1110 FULL BLOOD COUNT C

P X1114 ESR C

G K1010 CALCIUM (serum-no cuff) C

G E1011 PHOSPHATE (serum) C

G T1058 TSH C

U¯ R1013 CALCIUM / PHOSPHATE (24hr urine) C

G= P2837 VITAMIN D (25 hydroxy) C

G*P+P6P6 A1107 ANTENATAL SCREEN (Excl. Rubella IgM) C request Rubella IgM if recent exposure or rashG*GP+P6P6 G1108 ANTENATAL SCREEN + HIV (Excl. Rubella IgM) C request Rubella IgM if recent exposure or rashG*P+P6P6 C1354 ANTENATAL RESTRICTEDCG N1116 IRON STUDIES (FERRITIN incl.)C

P6P6 L1123 BLOOD GROUP + RBC ANTIBODY SCREEN (antenatal) C

B=**G( X1137 LUPUS ANTICOAGULANTC

BB=**P+P* D1136 INHERITED THROMBOTIC SCREEN C

B=P( R1128 LIMITED SCREEN FOR BLEEDING DISORDERC

BB=** B1138 VON WILLEBRAND DISEASEC

P Y1110 FULL BLOOD COUNT C

P X1114 ESRC

P P1112 HAEMOGLOBINC

P F1226 PLATELETSC

G J1117 FERRITIN C

P D3988 FOLATE (RBC)C

G=* X2379 FOLATE (serum)C

G=* S1119 VITAMIN B12C

P6P6 C1124 RBC ANTIBODY SCREEN antenatalC

P6P6 H1375 RBC ANTIBODY identificationC

P6P6 L1376 RBC ANTIBODY titrationC

G N1001 U&E, CREATININE C

GU¯ Q1005 CREATININE CLEARANCE C

U¯ V1006 PROTEIN (24hr urine) C

G C1262 UREA C

G L1261 CREATININE C

G H1007 URIC ACID (serum) C

( N1047 GTT pregnancy (100g, 3hr) C

( E4047 GTT pregnancy (75g, 2hr) C

G A1038 LIPOGRAM (fasting) C

G W1382 APOLIPOPROTEIN A1 & B C

G G1039 LIPOPROTEIN (a) C

G G1016 LIVER FUNCTION TESTS C

K P1020 BILIRUBIN (neonatal) C

K F3043 HEMATOCRIT (neonatal) C

F D1044 GLUCOSE (fasting) C

F X1045 GLUCOSE (random) C

( B1046 GLUCOSE TOLERANCE (2hr) C

G=F P3228 INSULIN RESISTANCE (fasting) C

P J1048 HbA1c (GLYCATED Hb) C

ENDOCRINOLOGY

HAEMATOLOGY

CERVICAL SCREENING

ENDOCRINOLOGY continue...CHEMISTRY TUMOUR MARKERS

OSTEOPOROSIS

D Y3180 DNA High risk C (Incl. GENOTYPING FOR HPV 16, 18 IF POSITIVE)

D Q3512 HERPES PCR (dry swab, vesicle fluid)C

P4792 LAMELLAR BODY COUNTC

DOWNS / NTD SCREEN (see separate request form)

G P1066 HIRSUTISM SCREEN (restricted) C

GG F1065 HIRSUTISM SCREEN (full)C

GG D1067 INFERTILITY female (rest 15 minutes)C

G X1068 INFERTILITY male (rest 15 minutes)C

H J1071 β-HCG PregnancyC

H Z1072 β-HCG SCREENC

( B1069 SEMEN ANALYSIS (<40% motility reflex SV)C

G G1062 THYROID PROFILE (TSH / T4)C

G* M1063 THYROID ANTIBODIESC

CYTOGENETICS A1337 AMNIOTIC FLUIDC

G Q1074 FSHC

G V1075 LHC

G H1076 OESTRADIOL (E ) �2 �C

ENDOCRINE - MENOPAUSAL INFECTIOUS DISEASES

ENDOCRINE - AMENORRHOEA

G Q1074 FSHC

G V1075 LHC

G H1076 OESTRADIOL (E ) � 2 �C

G S1073 PROLACTIN (rest 15 min)C

G T1058 TSHC

LIQUID BASED CYTOLOGY (LBC) - PRIMARY SCREENING

CO-TESTING (LBC AND HPV TESTING)

C PREGNANT /40W

C POST PARTUM /52W

C LACTATING

C POST MENOPAUSAL

LMP D D M M Y Y Y Y

CLINICAL HISTORY

C RADIO/CHEM. RxC IUD

C HORMONES (supply):

C LASER / CRYO. Rx

HPV TESTING - PRIMARY SCREENING

J5533 + HPVCYE DNA hr HPV (Incl. GENOTYPING FOR HPV 16, 18 IF POSITIVE)C

Q5398 + HPVCYE mRNA hr HPV (Incl. GENOTYPING FOR HPV 16, 18, 45 IF POSITIVE)C

FETAL MATURITY

CONVENTIONAL CYTOLOGY - PRIMARY SCREENING

PREVIOUS REFERENCE No.

GP Z1164 ARTHRITIS PROFILE (ESR / UA / CRP / RF) C

GGGU F5872 Sexual Health Screen (Incl HIV) C HIV ELISA, Syphilis, Hepatitis B sAg, Hepatitis C Ab, Urogenital panel (PCR) GGU Y5871 Sexual Health Screen (Excl HIV) C Syphilis, Hepatitis B sAg, Hepatitis C Ab, Urogenital panel (PCR) GD P1181 Genital Ulceration Panel PCR C (C. trachomatis, T. pallidum, HSV1&2, H. ducreyi ) (urine / swab in urine / LBC)D/U B1184 Genital discharge PCR (Gonococcal / Chlamydia)C

G J1186 Herpes simplex I / II SEROLOGY C

G K1171 CARDIOLIPIN & B2 GLYCOPROTEIN Ab C

G E3127 HIV ELISAC (Combined HIV-1/2 Ab + p24)G L2342 RPR onlyC

G Y1179 RUBELLA IMMUNITY (IgG only)C

G M1178 RUBELLA IgG / IgMC

G* F2445 SYPHILIS (automated antibody screening; C

positive results will reflex RPR)G M4490 HEP B IMMUNITY (HBsAb)C

G V1213 HEP B s AgC

Y1202 HEPATITIS C Ab C

MTBR AURAMINE, TB ID & susceptibility if culture +C

MSTDM MYCO - / UREAPLASMA Vaginal / Semen / CervicalC

MUMYCO Mycoplasma / Ureaplasma ID+ susceptibility (urine) C

MSTD Vaginal / cervical / urethral swab MC&SC

MUR URINE MC&SC

MSTREPB STREPTOCOCCUS GROUP B SCREENC

Site: Vaginal Rectal C C

DD * V4410 STREPTOCOCCUS GROUP B (PCR)C

J5533 + LBCGE DNA hr HPV (Incl. GENOTYPING FOR HPV 16, 18 IF POSITIVE)C

Q5398 + LBCGE mRNA hr HPV (Incl. GENOTYPING FOR HPV 16, 18, 45 IF POSITIVE)C

LBCGE LBCC CYTOGE CONVENTIONAL SMEARC

ORIGIN OF SMEAR

C ECTO/ENDO CERVIX

C ENDOMETRIUM

C VAGINAL

C POSTERIOR FORNIX

C VULVA

C LATERAL FORNIX FOR HORMONAL ASSESSMENT

C VAULT (HYSTERECTOMY)

B CITRATE tube must be full (blue stopper) F FLUORIDE tube (grey stopper)G SST GEL tube (gold stopper)GG 2x SST Gel tubes (gold stopper)H HEPARIN lithium tube (green stopper)P EDTA tube (purple stopper) 4ml

P6 EDTA tube (purple stopper) 6mlR NO GEL plain tube (red stopper) K Capillary bloodD Dry swab (no transport medium)(Black or Purple)DD 2x dry swabs (no transport medium) (Black or Purple)( Arrange with laboratory, on appointment only

U 25 ml random urine specimenU¸ 24hr urine collection without preservativeÜ On ice (refer patient to nearest depot)ÜÜ Seperate within 4 hours & Freeze asap after seperation= Separate asap Rest 15 minutes

SpecimenInstructions

Allergic to Penicillin? (ü) YES NO

Patient pregnant? (ü)NOYES

GYNAECOLOGY FORM

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902461 SKELETON A4 ENG

HOSPITAL STICKER

REFERRING DR.

PATHCARE CODE

Tel. (w)

Mr Mrs Ms Dr ProfTitle

DOBPatient IDPassport nr

PatientSurname

PatientFirst Name

Tel. (h) / cell

E-mail

Tel. (w)

PatientTitle

M F

st 1 Copy Dr & Code

nd2 Copy Dr & Code

rd3 Copy Dr & Code

Hospital Ward and Code

PERSON RESPONSIBLE FOR PAYMENT OF ACCOUNT ( compulsory - please complete)

GuarantorID No.

Surname

Postal Address

Medical Aid No.

Tel. (h)/cell

Medical Aid

Collected by

Site Priority Location Code

Date

Date

D D

D D

M M

M M

Y Y Y Y

Y Y Y Y

Time

TimeReceived by

SIGNATURE PATIENT CONSENT

Initials

HEPARINURINE EDTA CLOTTEDACDGELCITRATE FLUORIDE4ml 6ml

OTHER - please specify

SPECIMEN INFORMATION AND TEST COUNT

TESTCOUNT

ICD 10 CODE

E-mail

Single Twins TripletsBirths

D D M M Y Y Y Y

FASTING YES NO

LMP

OTHER TESTS AND CODES RELEVANT CLINICAL DATA AND PRESENT MEDICATION

1 12 2 3

File No.

IMP

OR

TAN

T

I certify that the above information is correct. I give specific consent for test analysis and fully understand the implications of the test(s) and I have received adequate pre test counselling. I hereby request and agree that all my pathology test results and accounts from Drs. Dietrich, Voigt, Mia & Partners (“PathCare”) may be sent to my nominated email address and cellphone number, to my medical aid administrators, medical practitioner and/ or insurance company. I indemnify PathCare against action that may be brought by virtue of this request and I understand that it is entirely my responsibility to safeguard access to my email. I undertake to pay outstanding monies not covered by the medical aid.

RE

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BARCO DE ST I CKERPRACTICE NO. 5200539

BARCODED STICKER AREA FOR URGENT RESULTS

ContactDetails

PleaseIndicate

ContactPerson

Fax Cell EmailTel

G*P+P6P6 A1107 ANTENATAL SCREEN C

G*GP+P6P6 G1108 A NTENATAL SCREEN + HIVC

P Y1110 F ULL BLOOD COUNTC

P P1112 H AEMOGLOBINC

G J1117 FERRITINC

P6P6 L1123 BLOOD GROUP + ANTIBODY SCREENC

P6P6 C1124 RBC ANTIBODY SCREEN antenatalC

P6P6 H1375 RBC ANTIBODY identification C

P6P6 L1376 R BC ANTIBODY titration C

G* S1188 T Pallidum Ab (automated antibody C screening; positive results will reflex RPR)

G L2342� � RPR onlyC

G M1178 RUBELLA IgG, IgM C

DOWN’S SYNDROME and OPEN NEURAL TUBE SCREENING

No

A

Ethnic origin:

Yes

w d

Weight: . kg

(date sonar done)

IVF pregnancy:

If yes, please complete:

Maternal & Gestational data

PreviousDowns/NTD:

Gestational age (sonar):

LMP (if no sonar done)

Date of egg collection:

Date of embryotransfer:

White Asian Black

T21 T18 T13 NTD

Type I DM (IDDM): No Yes Smoking: No

on d d m m y y y y

No

Yes

d

d

d

d

m

m

m

m

y

y

y

y

y

y

y

y

d d m m y y y y

DOB of egg donor: d d m m y y y y

B st1 Trimester sonar data (11w –13w6d)

CRL:

If biochemistry was done at 8 - 10w, please supply laboratory reference number:

Ultrasonographer :

. mm NT: . mm Nasal bone: Present Absent Unable to examineon

(date sonar done)

d d m m y y y y

Coloured

G Y1179 RUBELLA IgG onlyC

G V1213 HEB B sAgC

G E3127 HIV ELISA C

(combined HIV-1/2 Ab + p24)

F D1044 GLUCOSE fasting C

F X1045 GLUCOSE randomC

ANTENATAL TESTS

Please note that these are screening tests only with an approximate 60-90% detection rate and a false positive rate of 5-6%. These are NOT definitive diagnostic tests. Please consult your physician for advice.

Twins: No Yes If Yes: Dichorionic Monochorionic

None

V1236 Downs & NTD screen ® Please complete section AC

G1315 AFP for NTD screen® Please complete section A C

G/Amnfl.

G/Amnfl.

Please indicate ( ) which test is required, and complete the relevant section: ü Specimen:

G =*G =

H1237 Combined risk (biochemistry & sonar) (11w – 13w6d) ® Please complete sections A + B C

H1237 Combined risk calculation only (biochem already done) (11w – 13w6d) ® Please complete sections A + B C

H1237 Biochemistry only, without risk calculation (8w – 13w6d)C

H1237 Biochemistry only, with risk calculation (8w – 13w6d) ® Please complete section AC

nd 2 Trimester (15w – 20w6d)

st 1 Trimester

G =*

Ductus Venosus blood flow: Forward Reverse / Absent Not examined

Gestational age according to sonar: w d on d d m m y y y y Weight: . kg

DOWN SYNDROME FORM

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Patient pregnant? (ü) NOYES

902461 SKELETON A4 ENG

HOSPITAL STICKER

REFERRING DR.

PATHCARE CODE

Tel. (w)

Mr Mrs Ms Dr ProfTitle

DOBPatient IDPassport nr

PatientSurname

PatientFirst Name

Tel. (h) / cell

E-mail

Tel. (w)

PatientTitle

M F

st 1 Copy Dr & Code

nd2 Copy Dr & Code

rd3 Copy Dr & Code

Hospital Ward and Code

PERSON RESPONSIBLE FOR PAYMENT OF ACCOUNT ( compulsory - please complete)

GuarantorID No.

Surname

Postal Address

Medical Aid No.

Tel. (h)/cell

Medical Aid

Collected by

Site Priority Location Code

Date

Date

D D

D D

M M

M M

Y Y Y Y

Y Y Y Y

Time

TimeReceived by

SIGNATURE PATIENT CONSENT

Initials

HEPARINURINE EDTA CLOTTEDACDGELCITRATE FLUORIDE4ml 6ml

OTHER - please specify

SPECIMEN INFORMATION AND TEST COUNT

TESTCOUNT

ICD 10 CODE

E-mail

Single Twins TripletsBirths

D D M M Y Y Y Y

FASTING YES NO

LMP

OTHER TESTS AND CODES RELEVANT CLINICAL DATA AND PRESENT MEDICATION

1 12 2 3

File No.

IMP

OR

TAN

T

I certify that the above information is correct. I give specific consent for test analysis and fully understand the implications of the test(s) and I have received adequate pre test counselling. I hereby request and agree that all my pathology test results and accounts from Drs. Dietrich, Voigt, Mia & Partners (“PathCare”) may be sent to my nominated email address and cellphone number, to my medical aid administrators, medical practitioner and/ or insurance company. I indemnify PathCare against action that may be brought by virtue of this request and I understand that it is entirely my responsibility to safeguard access to my email. I undertake to pay outstanding monies not covered by the medical aid.

RE

Q. I

NF

O

S U H R Z

HO

SP

ITA

L S

TIC

KE

R

BARCO DE ST I CKERPRACTICE NO. 5200539

BARCODED STICKER AREA FOR URGENT RESULTS

ContactDetails

PleaseIndicate

ContactPerson

Fax Cell EmailTel