Microbiology Department
Level 4 Camelia Botnar Laboratories
Great Ormond Street Hospital NHS Foundation Trust
Great Ormond Street
London WC1N 3JH
DX 6640203 Bloomsbury 91WC
Tel: 020 7405 9200 (extension 0437 or 5280)
Molecular Investigations Request Form
Email: kathryn.harris@gosh.nhs.uk or john.hartley@gosh.nhs.uk
Patient Details
Name
DOB
Hospital number
Sample details
Sample
Description
Sample
Date
Sample
Number
Clinical Details
Assay
Broad-range 16S rDNA PCR (Bacteria)
Broad-range fungal PCR
Streptococcus pneumoniae real-time PCR
Neisseria meningitidis real-time PCR
Kingella kingae real-time PCR
Staphylococcus aureus real-time PCR
Streptococcus pyogenes real-time PCR
Streptococcus agalactiae real-time PCR
Enterobacteriaceae real-time PCR
Mycobacterium tuberculosis / Mycobacterium spp real-time PCR
Tick if required*
*Specific-real time PCR assays dramatically increase the yield from certain specimen types. Please contact us if you require more information about
this.
Referring Centre Details
Name of sender
Name of
Organisation
Telephone number
Email address
(we will telephone
significant results)
(reports can be
emailed to nhs.net
accounts)
Address
(for results)
Address
(for invoices)
(include PO number if
applicable)