General Test Requisition Form

Specialty: Physician **General Test Requisition Form** **Patient Information:** * **Patient Name:** Sarah Johnson * **Date of Birth:** 15/03/1988 * **NHS Number/Patient ID:** 9876543210 * **Gender:** Female * **Address:** 12 Elm Street, Anytown, AB1 2CD * **Contact Number:** 07700 900000 **Referring Clinician Information:** * **Referring Doctor:** Dr. Emily White * **Practice Name:** Anytown Medical Centre * **Contact Number:** 01234 567890 * **Date of Request:** 01 November 2024 **Tests Requested:** * Full Blood Count (FBC) * Urea and Electrolytes (U&E) * Liver Function Tests (LFTs) * Thyroid Function Tests (TFTs) * HbA1c **Reason for Request (Clinical Indication):** Patient presenting with fatigue, unexplained weight gain, and increased thirst for the past three months. Suspect potential metabolic or endocrine dysfunction. Initial blood pressure reading elevated. **Relevant Clinical History:** * Family history of Type 2 Diabetes Mellitus. * No known allergies. * Current medications: None. * Recent viral infection 6 weeks ago. **Specimen Collection Details:** * **Specimen Type:** Venous Blood * **Date/Time of Collection:** To be collected * **Fasting Required:** Yes, 10-12 hours fasting. **Urgency:** * Routine **Additional Notes/Instructions for Lab:** Please alert referrer immediately if critical values are detected, especially for glucose or potassium levels. **Copy Results To:** Dr. Thomas Kelly (Consultant Endocrinologist) **Signature of Referring Clinician:** Dr. Emily White (Electronic Signature) **Date:** 01 November 2024