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Thrombosis presentation by Dr AN Lategan

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Request Form

REQUEST FORM

(Click here to view the full size Acrobat PDF format file)

1.	How to complete the form
	The grey areas of the form to be completed and signed by the patient - in the presence of the venesectionist. The white areas of the form to be completed and signed by the venesectionist.
	For the Patient:
	Use capital letters only Use a black pen Please complete all fields in the grey area You must supply us with the detail of a nominated medical practitioner to enable the insurance company to refer you to this practitioner for post test counselling should your HIV-test results be reactive You must sign if you voluntarily elect to waiver your right to HIV pretest counselling You must sign consent to HIV testing in the presence of the venesectionist
	For the Venesectionist:
	User capital letters only Use a black pen Cross test blocks neatly Please make sure that your patient signs the request form Ensure that the patient's surname and initials are written clearly and correctly on every tube Ensure that you sign section G verification of patient's identification Please supply us with your practice / council no Ensure that the ID number is correct according to the patient's ID document
2.	Fields of importance
	Section A:
	Patient detail Identity number - this number must be correct according to the ID document
	Section B:
	Applicable to minors under the age of 18 years.
	Section C:
	Nominated doctor's information to enable the insurance company to refer the patient to this doctor for post test counselling if HIV results are reactive
	Section D & E:
	Signature of patient for consent to do tests
	Section F:
	E-mail Code - this code must be captured on our Meditech system to trigger the e-mail notification to the Broker informing him/her that patient has been bled.
	Section G:
	Venesectionist detail and signature - Collection date and time
	Section H:
	Tests to be marked clearly to ensure that the correct test will be performed.
3.	Order Forms: Cape Town Port Elizabeth Gauteng KZN East London Port Elizabeth Bloemfontein Rustenburg Vaal Triangle

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