Pathology request form ONLINE

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)