Medicare card number Office use only PATHOLOGY REQUEST FORM A/3210 LABORATORY COPY Surname, Given names (including middle initials) Sex: Patient address: Tests for QFG: Date of birth: Your reference: Phone (Home): Phone (Work): Tests for SNP: Hormonal Infection Genetic Other Group & Antibodies *LH * HEP Bs Ag * KARYOTYPE * CA125 Full blood count/FBE *PROG * HEP C Ab * CF # * Vitamin D CRP *E2 * TPPA * AZF/DAZ $ ** DHEAS LFT *FSH * HIV Ab * FRAGILE X # ** SHBG U&E *PROL * RUB IgG ** F.A.I * TESTO * VZV IgG ** SAb IgG * TFT ***HTLV Ab *HCG * TSH ***CMV IgG ** AMH $ Anticardiolipin Antibodies [IgG, IgM] Ferritin Lupus anticoagulant and lupus inhibitor # Fasting Homocysteine Activated Protein C resistance # Non Fasting HbA1C Pregnant Horm Therapy PAP Smear SITE n n Endometrium n Other n Post Natal n Post Menopause n Radiotherapy n IUCD n Abnorm Bleedingn Cervix Vaginal Vault Anti-Thrombin III # Other Other TEST PERFORMED AT * QFG ** IVF AUSTRALIA $ PRIVATE BILLING - NO MEDICARE REBATE *** MELBOURNE IVF # MEDICARE REBATE MAY BE APPLICABLE Clinical notes: n URGENT! Phone n Fax REQUESTING DOCTOR’S SIGNATURE AND REQUEST DATE nBy time: Phone/Fax no: Private n Schedule Fee n Bulk Bill IMPORTANT Global n In cycle patient MUST attend QFG Vet Affairs no: Benign n Suspicious n collection centre APPEARANCE OF CERVIX DOCTOR n 8 EDC CERVICAL CYTOLOGY Fasting INS Protein S, Protein C # ** Chlam IgG n n n n LNMP Fasting GLUC Prothrombin Gene Mutation G20210A # ***Inhibin B Fasting Requesting Doctor’s signature Copy reports to: Requesting Doctor (provider number, surname and initials, address) n 3if Self Determine Staff ID/Location code/Collection Type (stamp) Pay Cat SST EDTA Unspun LIH LIH Gel Tube Tube TubeTubeTube Con CodeHisto Urine Frozen Swab Pap Cit Tube Thp MEDICARE ASSIGNMENT (Section 20A of the Health Insurance Act 1973): I assign my right to benefits to the approved pathology practitioner who will render the requested pathology service(s). ACCOUNT STATEMENT: I understand that if any of the tests requested are not eligible for a Medicare rebate I will receive an account which I agree to pay in full. PATIENT’S SIGNATURE AND DATE: PATIENT ContSlide Thin Prep 8 Date Collected: Other: PERSON COLLECTING SPECIMEN(S) TO COMPLETE: I certify I established the identity of the patient named on this request, collected and immediately labelled the accompanying / / specimen(s) with the patient’s details. PRACTITIONER’S USE ONLY (Reason patient cannot sign) Name: Time Collected: COLLECTOR 8 : Describe / / PATIENT STATUS Was or will the patient be, at the time of the service or when the specimen was obtained: a private patient in a private hospital or approved day hospital facility n YES n NO a private patient in a recognised hospital n YES n NO a Medicare (public) patient in a recognised hospital n YES n NO an outpatient of a recognised hospital n YES n NO Medicare card number PATHOLOGY REQUEST FORM PATIENT COPY Surname, Given names (including middle initials) Sex: Date of birth: Your reference: Patient address: Phone (Home): Requesting Doctor (provider number, surname and initials, address) Tests for QFG: Hormonal Infection Genetic Other Tests for SNP: Group & Antibodies *LH * HEP Bs Ag * KARYOTYPE * CA125 Full blood count/FBE *PROG * HEP C Ab * CF # * Vitamin D CRP *E2 * TPPA * AZF/DAZ $ ** DHEAS LFT *FSH * HIV Ab * FRAGILE X # ** SHBG U&E *PROL * RUB IgG * TESTO * VZV IgG *HCG ** SAb IgG * TFT ***HTLV Ab ** AMH $ ***Inhibin B * TSH ***CMV IgG ** Chlam IgG Phone (Work): ** F.A.I Anticardiolipin Antibodies [IgG, IgM] Ferritin Lupus anticoagulant and lupus inhibitor # Fasting Homocysteine Activated Protein C resistance # Prothrombin Gene Mutation G20210A # HbA1C Fasting GLUC Fasting INS PAP Smear Protein S, Protein C # Anti-Thrombin III # Other Other Your doctor has recommended that you use QFG Pathology Service or SNP. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor. PRIVACY NOTE The information provided will be used to assess any Medicare benefit payable for the services rendered and to facilitate the proper administration of government health programs, and may be used to update enrolment records. Its collection is authorised by provisions of the Health Insurance Act 1973. The information may be disclosed to the Department of Health and Ageing or to a person in the medical practice associated with the claim, or as authorised by law. Queensland Fertility Group | Boundary Court Level 2 | 55 Little Edward Street SPRING HILL Q 4000 | 1800 111 IVF www.qfg.com.au ACN 010 514 397 Freecall 1800 111 483 www.qfg.com.au QFG Collection Centres ***IMPORTANT - In cycle patients MUST attend QFG*** BRISBANE Spring Hill [Main Clinic] Level 2 Boundary Court 55 Little Edward Street SPRING HILL QLD 4000 Spring Hill Level 3 Watkins Medical Centre 225 Wickham Terrace SPRING HILL QLD 4000 Tel Monday - Friday Weekends [07] 3015 3000 6.30am - 5.00pm Sat/Sun 7.00am - 9.00am [07] 3015 3195 6.30am - 5.00pm Sat only 7.00am - 9.00am [07] 3245 3067 7.00am - 9.30am N/A [07] 3353 4710 7.00am - 9.30am N/A [07] 4638 5243 8.30am - 4.00pm N/A [07] 4965 6500 9.00am - 3.00pm N/A [07] 4772 8900 8.00am - 3.30pm N/A [07] 5564 8455 7.30am - 9.30am Sat only 7.30am - 8.30am Capalaba 149 Old Cleveland Road CAPALABA QLD 4157 Everton Park North West Specialist Centre 125 Flockton Street EVERTON PARK QLD 4053 TOOWOOMBA+ Suite 15 Toowoomba Specialist Centre 9 Scott Street TOOWOOMBA QLD 4350 MACKAY NORTH+ Stanley House 5 Discovery Lane NORTH MACKAY QLD 4740 TOWNSVILLE+ Level 1 Oxford Medical Suites 18 Oxford Street HYDE PARK QLD 4812 GOLD COAST Suite 6 Pindara Place 13 Carrara Street BENOWA QLD 4217 Toowoomba, Mackay & Townsville collections by appointment only .For all clinics, please check public holiday times with your clinic + Sullivan Nicolaides Collection Centres For Collection Centre locations, opening hours and information regarding appointments go to www.snp.com.au or phone Patient Services Support on 1300 732 030. ***IN CYCLE PATIENTS MUST ATTEND QFG*** Guidelines for Fasting Bloods • • Fasting is usually overnight for a minimum period of 8 hours, although 12 hours is preferred All food and beverages should be witheld with the exception of water W:\Forms\Blood Collection Forms\Pathology Request Form 0114 • • Medication should be stopped on the instructions of your Doctor Most common tests that require fasting are Glucose and Lipid testing (cholesterol, triglycerides and HDL)
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