Conjugated Bilirubin

PA

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OL

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Y R

OU

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RD

ER

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th

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ay n

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3266

TEA

R Bed Number (forPhlebotomy Collections)

Patient ID Checked Samples Collected

Date: Time:

CLINICAL DETAILS - WHAT QUESTIONS DO YOU WANT ANSWERED?

ETHNIC ORIGIN .................................................................

TREATMENTDate of onsetPregnant Y N Immunocompromised Y N

EDD Month Year Danger of Infection Y N

A S E P A R A T E S P E C I M E N I S R E Q U I R E D F O R E A C H B L O C K O F T E S T SChemical Pathology (SST Yellow Top)

Lipid profile

Total Cholesterol

Uric acid

Magnesium

Amylase

CRP

CK

Urine ACR

Glucose (Fluoride Grey Top)

Hb A1C (Purple Top EDTA)

Thyroid Profile

LH/FSH

Prolactin

Oestradiol

Testosterone

Progesterone

PSA

HCG

AFP

CEA

CA 125

CA 19.9

CA 15.3

(SST Yellow Top)

THIS REQUEST HAS “ROUTINE” PRIORITY

DOCTOR’S NAME (PRINT) ....................................... Bleep No. .........................

SIGNATURE .............................................................. Date .................................

Immunology (SST Yellow Top )

Rheumatoid Factor

Antinuclear antibodies

ds DNA Antibodies

ENA

ANCA

Thyroid antibodies

Gastric Parietal Cell Abs.

Liver Disease Autoantibodies

Coeliac Screen

Total IgE

Specific IgE (please specify)

Acetyl Choline Rec. Ab

Endocrine Ab. (please specify)

CSF Immunochemistry(CSF & SST Blood)

Virology (SST Yellow Top )Antenatal Screen

HIV

Syphilis - (screen only)

Pre Hep B. Vaccine

Post Hep B. Vaccine

Pre Hep A. Vaccine

Rubella screen non-pregnant

CMV IgG screen

VZV IgG screen

Toxoplasma IgG

Hep A IgM

Hep B surface Ag

Hep C IgG

Glandular fever(EBV, CMV, Toxo)

EBV

Mycoplasma IgM

Measles IgG

Mumps IgG

Virology (Purple Top EDTA)Viral Load

Specify Virus.........................

Haematology (Purple Top EDTA)

FBC (inc. WBC Differential)

Reticulocytes

Paul Bunnell

Haemoglobinopathy screen

ANC Screen

Partner

Preconception

G-6-PD Screen

ESR (Seditainer Black Top)

Haematinics (SST Yellow Top)Ferritin

Folate

Vitamin B12

Erythropoietin

Flowcytometry (Purple Top EDTA)

Harrison Wing profile

Lymphocyte sub-sets

Blood Transfusion (PINK Top EDTA)

Group & Save

Direct Antiglobulin

Kleihauer

Prophylactic Anti-D

Y N

Dose Given .......................................

Date Given ........................................

Group & Crossmatch

Date required ...................................

Time required ...................................

No. of units ......................................

Haemostasis

Coagulation screen(1 x Citrate Blue Top)

INR (warfarin)(1 x Citrate Blue Top)

D-Dimer(1 x Citrate Blue Top)

Thrombophilia screen(4 x Citrate Blue Top+

Antiphospholipid Anti(2 x Citrate Blue Top+

Anticoagulant Therapy

Yes No

Specify:

Other Tests or Blood Products (Please write clearly in CAPITA

PID NUMBER

SURNAME

FORENAME

DATE OF BIRT FH M

NHS NUMBER

GP ATTACH

ADDRESSOGRAPH

LABEL

REPORT DESTINATION

CONSULTANT/G.P.

SPECIALITY

Date & Time of receipt by Laboratory

CL

INIC

AL

LA

BO

RA

TO

RY

SE

RV

ICE

S

Ro

uti

ne

BLO

OD

Ord

ers

WV

G001

Re

f-2

32

66

TE

AR Bed Number (for

Phlebotomy Collections)Patient ID Checked andSamples Collected by:

Date: Time:

CLINICAL DETAILS - WHAT QUESTIONS DO YOU WANT ANSWERED?

ETHNIC ORIGIN .................................................................

TREATMENTDate of onsetPregnant Y N Immunocompromised Y N

EDD Month Year Danger of Infection Y N

A S E P A R A T E S P E C I M E N I S R E Q U I R E D F O R E A C H B L O C K O F T E S T SChemical Pathology (SST Yellow Top)

Full Lipid Profile

Total Cholesterol

Uric acid

Magnesium

Amylase

CRP

CK

Urine ACR

Glucose (Fluoride Grey Top)

Hb A1C (Purple Top EDTA)

Thyroid Profile

LH/FSH

Prolactin

Oestradiol

Testosterone

Progesterone

PSA

HCG

CA 125

Pro-BNP

(SST Yellow Top)

THIS REQUEST HAS “ROUTINE” PRIORITY

DOCTOR’S NAME (PRINT) ....................................... Bleep No. .........................

SIGNATURE .............................................................. Date .................................

Immunology (SST Yellow Top )

Immunology (SST Yellow Top )

Rheumatoid Factor

Antinuclear antibodies

ds DNA Antibodies

ENA

ANCA

Thyroid antibodies

Gastric Parietal Cell Abs.

Liver Disease Autoantibodies

Coeliac Screen

Total IgE

Specific IgE (please specify)

Acetyl Choline Rec. Ab

Endocrine

(Sample to Lab in 2 hours)

ADR, DABS

(CH100, AGP)

Ab. (please specify)

Virology (SST Yellow Top )Antenatal Screen

HIV

Syphilis - (screen only)

Pre Hep B. Vaccine

Post Hep B. Vaccine

Pre Hep A. Vaccine

Rubella screen non-pregnant

CMV IgG screen

VZV IgG screen

Toxoplasma IgG

Hep A IgM

Hep B surface Ag

Hep C IgG

Glandular fever(EBV, CMV, Toxo)

EBV

Mycoplasma IgM

Measles IgG

Mumps

Viral Rash Investigations

IgG

Virology (Purple Top EDTA)Viral Load

Specify Virus.........................

Haematology (Purple Top EDTA)

ESR

Haematinics

(SST Yellow Top)

Flowcytometry (Purple Top EDTA)

Harrison Wing profile

Lymphocyte sub-sets

Blood Transfusion (PINK Top EDTA)

Group & Save

Direct Antiglobulin

Kleihauer

Prophylactic Anti-D

Y N

Dose Given .......................................

Date Given ........................................

Group & Crossmatch

Date required ...................................

Time required ...................................

No. of units ......................................

Haemostasis + ThrombosisCoagulation screen (INR & APTT)(1 x Citrate Blue Top)

INR (warfarin)(1 x Citrate Blue Top)

D-Dimer(1 x Citrate Blue Top)

Thrombophilia screen inc APA profile(4 x Citrate Blue Top+ 1 SST Yellow Top)

Antiphospholipid Antibogy Profile Only(2 x Citrate Blue Top+ 1 SST Yellow Top)

Special Coagulation screen(INR, APTT, Fibinogen) (1xcitrate blue top)

Anticoagulant Therapy

Yes No

Specify:

Other Tests or Blood Products (Please write clearly in CAPITAL Letters,Do NOT use abbreviations:)

PID NUMBER

SURNAME

FORENAME

DATE OF BIRT FH M

NHS NUMBER

GP ATTACH

ADDRESSOGRAPH

LABEL

REPORT DESTINATION

CONSULTANT/G.P.

SPECIALITY

Date & Time of receipt by Laboratory

BR

BLVR

BCBIL

BBN

BLPD

BTCHOL

BUA

BMGN

BAMY

BCRP

BCK

IRON BIRON

UACR

BTSH

BU

BGTROPH

BPROL

BE2

BTET

BPROG

BPSA

BHCG

BC125

BBNP

Troponin BTROP

C3C4 C34

RFWP

HEP2

DNAWP

ENID

ANCAS

THYR

AIP

AIP

COELWP

RIST

ACH

BGParathyroid Hormone BPTH(Sample to Lab in 2 hours)

LU

BHA1C

ANCS

HIV

SYGA

HBCA

HAVG

RUBS

CMVG

VZG

TOXG

HAVM

HBS

HEPC

GFS

EBV

ESR

Erythropoietin

Methylmelanonic Acid (BMMA)

EPO

Ferritin

Folate

Vitamin B12

25 hydroxy Vitamin D

FERR

SFOL A

B25D

SS

VB12

T4T8+FBC

LSS+FBC

GS

BDAGT

KLEI

GS+EI

MYCOM

MEAG

MUMPG

HBSA

FBC (inc. WBC Differential)

Reticulocytes

Paul Bunnell

Haemoglobinopathy screen

ANC Screen

Partner

Preconception

G-6-PD Screen

FBC

RETICS+FBC

PBT+FBC+FILM

FBC+G-6-PD

FBC+MPI+FILM(please mark clearly as URGENT)

FBC+SICK

Urea

Renal Profile Malaria Studies

Liver Profile

Bone Profile

Complement activity

Conjugated Bilirubin

PA

TH

OL

OG

Y R

OU

TIN

E O

RD

ER

S

Hav

e yo

u la

bel

led

th

e S

amp

le &

Req

ues

t F

orm

Co

rrec

tly?

If D

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amp

le m

ay n

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be

pro

cess

ed.WV

G00

1R

ef-2

3266

TEA

R Bed Number (forPhlebotomy Collections)

Patient ID Checked Samples Collected

Date: Time:

CLINICAL DETAILS - WHAT QUESTIONS DO YOU WANT ANSWERED?

ETHNIC ORIGIN .................................................................

TREATMENTDate of onsetPregnant Y N Immunocompromised Y N

EDD Month Year Danger of Infection Y N

A S E P A R A T E S P E C I M E N I S R E Q U I R E D F O R E A C H B L O C K O F T E S T SChemical Pathology (SST Yellow Top)

Lipid profile

Total Cholesterol

Uric acid

Magnesium

Amylase

CRP

CK

Urine ACR

Glucose (Fluoride Grey Top)

Hb A1C (Purple Top EDTA)

Thyroid Profile

LH/FSH

Prolactin

Oestradiol

Testosterone

Progesterone

PSA

HCG

AFP

CEA

CA 125

CA 19.9

CA 15.3

(SST Yellow Top)

THIS REQUEST HAS “ROUTINE” PRIORITY

DOCTOR’S NAME (PRINT) ....................................... Bleep No. .........................

SIGNATURE .............................................................. Date .................................

Immunology (SST Yellow Top )

Rheumatoid Factor

Antinuclear antibodies

ds DNA Antibodies

ENA

ANCA

Thyroid antibodies

Gastric Parietal Cell Abs.

Liver Disease Autoantibodies

Coeliac Screen

Total IgE

Specific IgE (please specify)

Acetyl Choline Rec. Ab

Endocrine Ab. (please specify)

CSF Immunochemistry(CSF & SST Blood)

Virology (SST Yellow Top )Antenatal Screen

HIV

Syphilis - (screen only)

Pre Hep B. Vaccine

Post Hep B. Vaccine

Pre Hep A. Vaccine

Rubella screen non-pregnant

CMV IgG screen

VZV IgG screen

Toxoplasma IgG

Hep A IgM

Hep B surface Ag

Hep C IgG

Glandular fever(EBV, CMV, Toxo)

EBV

Mycoplasma IgM

Measles IgG

Mumps IgG

Virology (Purple Top EDTA)Viral Load

Specify Virus.........................

Haematology (Purple Top EDTA)

FBC (inc. WBC Differential)

Reticulocytes

Paul Bunnell

Haemoglobinopathy screen

ANC Screen

Partner

Preconception

G-6-PD Screen

ESR (Seditainer Black Top)

Haematinics (SST Yellow Top)Ferritin

Folate

Vitamin B12

Erythropoietin

Flowcytometry (Purple Top EDTA)

Harrison Wing profile

Lymphocyte sub-sets

Blood Transfusion (PINK Top EDTA)

Group & Save

Direct Antiglobulin

Kleihauer

Prophylactic Anti-D

Y N

Dose Given .......................................

Date Given ........................................

Group & Crossmatch

Date required ...................................

Time required ...................................

No. of units ......................................

Haemostasis

Coagulation screen(1 x Citrate Blue Top)

INR (warfarin)(1 x Citrate Blue Top)

D-Dimer(1 x Citrate Blue Top)

Thrombophilia screen(4 x Citrate Blue Top+

Antiphospholipid Anti(2 x Citrate Blue Top+

Anticoagulant Therapy

Yes No

Specify:

Other Tests or Blood Products (Please write clearly in CAPITA

PID NUMBER

SURNAME

FORENAME

DATE OF BIRT FH M

NHS NUMBER

GP ATTACH

ADDRESSOGRAPH

LABEL

REPORT DESTINATION

CONSULTANT/G.P.

SPECIALITY

Date & Time of receipt by Laboratory

CL

INIC

AL

LA

BO

RA

TO

RY

SE

RV

ICE

S

Ro

uti

ne

BLO

OD

Ord

ers

WV

G001

Re

f-2

32

66

TE

AR Bed Number (for

Phlebotomy Collections)Patient ID Checked andSamples Collected by:

Date: Time:

CLINICAL DETAILS - WHAT QUESTIONS DO YOU WANT ANSWERED?

ETHNIC ORIGIN .................................................................

TREATMENTDate of onsetPregnant Y N Immunocompromised Y N

EDD Month Year Danger of Infection Y N

A S E P A R A T E S P E C I M E N I S R E Q U I R E D F O R E A C H B L O C K O F T E S T SChemical Pathology (SST Yellow Top)

Full Lipid Profile

Total Cholesterol

Uric acid

Magnesium

Amylase

CRP

CK

Urine ACR

Glucose (Fluoride Grey Top)

Hb A1C (Purple Top EDTA)

Thyroid Profile

LH/FSH

Prolactin

Oestradiol

Testosterone

Progesterone

PSA

HCG

CA 125

Pro-BNP

(SST Yellow Top)

THIS REQUEST HAS “ROUTINE” PRIORITY

DOCTOR’S NAME (PRINT) ....................................... Bleep No. .........................

SIGNATURE .............................................................. Date .................................

Immunology (SST Yellow Top )

Immunology (SST Yellow Top )

Rheumatoid Factor

Antinuclear antibodies

ds DNA Antibodies

ENA

ANCA

Thyroid antibodies

Gastric Parietal Cell Abs.

Liver Disease Autoantibodies

Coeliac Screen

Total IgE

Specific IgE (please specify)

Acetyl Choline Rec. Ab

Endocrine

(Sample to Lab in 2 hours)

ADR, DABS

(CH100, AGP)

Ab. (please specify)

Virology (SST Yellow Top )Antenatal Screen

HIV

Syphilis - (screen only)

Pre Hep B. Vaccine

Post Hep B. Vaccine

Pre Hep A. Vaccine

Rubella screen non-pregnant

CMV IgG screen

VZV IgG screen

Toxoplasma IgG

Hep A IgM

Hep B surface Ag

Hep C IgG

Glandular fever(EBV, CMV, Toxo)

EBV

Mycoplasma IgM

Measles IgG

Mumps

Viral Rash Investigations

IgG

Virology (Purple Top EDTA)Viral Load

Specify Virus.........................

Haematology (Purple Top EDTA)

ESR

Haematinics

(SST Yellow Top)

Flowcytometry (Purple Top EDTA)

Harrison Wing profile

Lymphocyte sub-sets

Blood Transfusion (PINK Top EDTA)

Group & Save

Direct Antiglobulin

Kleihauer

Prophylactic Anti-D

Y N

Dose Given .......................................

Date Given ........................................

Group & Crossmatch

Date required ...................................

Time required ...................................

No. of units ......................................

Haemostasis + ThrombosisCoagulation screen (INR & APTT)(1 x Citrate Blue Top)

INR (warfarin)(1 x Citrate Blue Top)

D-Dimer(1 x Citrate Blue Top)

Thrombophilia screen inc APA profile(4 x Citrate Blue Top+ 1 SST Yellow Top)

Antiphospholipid Antibogy Profile Only(2 x Citrate Blue Top+ 1 SST Yellow Top)

Special Coagulation screen(INR, APTT, Fibinogen) (1xcitrate blue top)

Anticoagulant Therapy

Yes No

Specify:

Other Tests or Blood Products (Please write clearly in CAPITAL Letters,Do NOT use abbreviations:)

PID NUMBER

SURNAME

FORENAME

DATE OF BIRT FH M

NHS NUMBER

GP ATTACH

ADDRESSOGRAPH

LABEL

REPORT DESTINATION

CONSULTANT/G.P.

SPECIALITY

Date & Time of receipt by Laboratory

BR

BLVR

BCBIL

BBN

BLPD

BTCHOL

BUA

BMGN

BAMY

BCRP

BCK

IRON BIRON

UACR

BTSH

BU

BGTROPH

BPROL

BE2

BTET

BPROG

BPSA

BHCG

BC125

BBNP

Troponin BTROP

C3C4 C34

RFWP

HEP2

DNAWP

ENID

ANCAS

THYR

AIP

AIP

COELWP

RIST

ACH

BGParathyroid Hormone BPTH(Sample to Lab in 2 hours)

LU

BHA1C

ANCS

HIV

SYGA

HBCA

HAVG

RUBS

CMVG

VZG

TOXG

HAVM

HBS

HEPC

GFS

EBV

ESR

Erythropoietin

Methylmelanonic Acid (BMMA)

EPO

Ferritin

Folate

Vitamin B12

25 hydroxy Vitamin D

FERR

SFOL A

B25D

SS

VB12

T4T8+FBC

LSS+FBC

GS

BDAGT

KLEI

GS+EI

MYCOM

MEAG

MUMPG

HBSA

FBC (inc. WBC Differential)

Reticulocytes

Paul Bunnell

Haemoglobinopathy screen

ANC Screen

Partner

Preconception

G-6-PD Screen

FBC

RETICS+FBC

PBT+FBC+FILM

FBC+G-6-PD

FBC+MPI+FILM(please mark clearly as URGENT)

FBC+SICK

Urea

Renal Profile Malaria Studies

Liver Profile

Bone Profile

Complement activity

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