FOR LAB USE ONLY GP Request for Laboratory Services PLEASE AFFIX SPECIMEN MICROBIOLOGY DEPARTMENT NUMBER BARCODE LABEL C. P. L., St. James’s Hospital, Dublin 8. HERE Tel.: 4162941 / 4162966 / 4162967 Patient Details (Complete Fully OR Attach an Addressograph Label inside the dotted line below): Surname First Name Male Date of Birth / / Female Ethnicity (if relevant) Patient’s Address: Doctor’s Name Doctor’s SJH Lab Code Doctor’s Signature Medical Council Registration Number Clinical Details Date Taken: Practice address or practice stamp here Practice Telephone Number: This is mandatory to ensure the doctor can be contacted during routine laboratory working hours 8am to 8pm. Drug / Antibiotic Therapy Time Taken: SPECIMENS (Please Tick): Blood Urine Date/Time Received: Stool Swab Other General Microbiology Culture & Sensitivity Fungal Culture STI Molecular Investigations [ ] Urine [ ] Nail Clippings [ ] Swab [ ] Hair [ [ [ [ [ [ ] Skin Scrapings [ ] Fluid Site:__________________ Site: __________________ [ ] Sputum C/S [ ] Stools Investigation [ ] Sputum TB [ ] Stools Ova & Parasites** [ ** performed only when relevant clinical details are provided. ] MRSA Screen Swab ] CT/NG (Endocervical Swab) ] CT/NG (Vaginal Swab) ] CT/NG (First Void Urine) ] CT/NG (Pharyngeal Swab) ] CT/NG (Rectal Swab) Viral Molecular Investigations (Green Top Viral Swab) (Nasal/Throat/Groin) [ ] Herpes Simplex Virus (HSV) [ ] Varicella Zoster Virus (VZV) Site: _____________ Serology (Order either profiles or individual Investigations as appropriate) PROFILES INDIVIDUAL INVESTIGATIONS [ ] STI Screen (Syphilis, HIV, Hep B sAg [ ] Syphilis [ ] Measles / Mumps / Rubella Screen IgG [ ] HIV [ ] Viral Hepatitis B & C Screen [ ] Hep B sAg (Hep B sAg, Hep C Ab) [ ] Hep B sAb [ ] Hepatitis B Infection Status (Hep B sAg, Hep B cAb) [ ] Current Hepatitis C infection (Hep C core Ag) (Post-Vaccination) [ ] Hep B core Ab [ ] Hep C Ab [ ] Hep C core Ag [ ] Measles [ ] Mumps [ ] Rubella [ ] Hep A IgG [ ] VZV IgG Specimen requirements and other information are available on www.stjames.ie by clicking on the “Lab Services” Tab. For further information on ordering hepatitis screens please refer to “Viral Hepatitis Testing for General Practitioners” in the Policies & Guidelines section under Lab services. P904B version 5