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Lancet.Co.Za/ PATHOLOGISTS PRACTICE NO L A N C E T LAB NO. LAB NO. LABORATORIES ITEM NO. 013288 WEB SITE: http://www.lancet.co.za/ PATHOLOGISTS PRACTICE NO. 5201055 AFFIX BARCODE LABEL HERE AFFIX BARCODE LABEL HERE HELP DESK NUMBER 0800 110 292 IN HOSP. TRAUMA URGENT ROUTINEFASTING RANDOM PT.REG SDCPT. REG CLI PATIENT PATIENT CONTACT PERSON CODE TEL FAX YY Y Y FOR RESULTS REFERRING DOCTOR TABITHA ANN HUME - HUMET00 COPY DOCTOR COPY DOCTOR / FILE NO / HOSPITAL & WARD HOSPITAL NO DDMMYYYY COLLECTION HOUR MIN. COLLECTION DATE VENESECTIONIST SUBMITTED TIME PATIENT DETAILS MRI SURNAME FIRST NAME TITLE SEX MF DDMMYYYY PATIENT PATIENT ID NUMBER DATE OF AGE BIRTH TEL NO GUARANTOR (ACCOUNT) DETAILS POSTAL SURNAME TITLE ADDRESS INITIALS FIRST NAME CODE GUARANTOR ID NO. HOME ADDRESS CODE TEL (H) CELL E-MAIL CODE I GIVE CONSENT FOR TESTS, FOR THE RELEASE OF DIAGNOSTIC ICD10 CODES WHICH IS CURRENTLY A LEGAL Signature TEL (W) EMPLOYER REQUIREMENT FOR REIMBURSEMENT PURPOSES AND ANY OTHER DEFINED PURPOSE AS STIPULATED IN THE CONTRACT BETWEEN THE PATIENT AND HIS/HER MEDICAL SCHEME AND GUARANTEE PAYMENT OF ANY OUTSTANDING AMOUNTS NOT COVERED BY MEDICAL AID OR EXCEEDING THE ESTIMATE QUOTE. MEDICAL AID DETAILS MED. AID CARD MED. PLAN MEDICAL DEPENDANT VERIFIED Y N AID OPTION AID NO. CODE ACCOUNT AMOUNT RECEIPT AUTHORISATION NAPPI CASH CREDIT CARD CHEQUE NUMBER R NUMBER NUMBER CODE GENERAL ENDOCRINE HIV TESTS HAEMATOLOGY ICD 10 CODES W226 17-OH PROGESTERONE DIAGNOSTIC TESTS: S360 ABNORMAL HB/THAL SCR E H455 HIV Ab (ELISA) ONLY CLINICAL INFORMATION A307 ACTH (on ice) 2x E Y366 ANTENATAL Ab SCREEN E C155 ALDOSTERONE L309 HIV Ab+WEST BLOT (If Positive) (Indirect Coombs) C209 ANDROSTENEDIONE X524 HIV WEST BLOT (Confirmatory) V363 BLOOD GROUP+Rhesus E D400 P24 ANTIGEN E P415 ANTI-MULLERIAN HORMONE X365 COOMBS - Direct E E D210 CORTISOL - Serum D232 PCR QUALITATIVE HIV V386 ESR THERAPEUTIC MONITORING H352 FBC / PLATELETS E OTHER TESTS E211 DHEA-S G397 CD 4 COUNT E G351 FBC / PLATELETS / ESR E K216 FSH X547 HIV IMMUNE MONITORING 2x E F396 FLOW CYTOMETRY H E L217 GASTRIN - Fasting on Ice B (CD4 & Viral Load Only) (Please specify under “other tests”) F9 GROWTH HORMONE F401 HIV VIRAL LOAD E L019 HAEMOLYTIC PROFILE B E B208 HIRSUTISM PROFILE 2x B VIRAL STUDIES K355 Hb Only E SPECIMENS TAKEN F9 INFERTILITY SCREEN MF P358 MALARIA E X296 CMV Ab TAKEN REC DEPARTMENT TAKEN REC DEPARTMENT F9 INSULIN R359 PAUL BUNNEL CITRATE C CSF Csf T223 LH U293 COXSACKIE B VIRUS L355 PLATELETS E CLOTTED B FAECES F V225 OESTRADIOL (E2) Y297 EPSTEIN-BARR VIRUS M356 RETICULOCYTES E CLOT (No SST) BP SWAB S X227 PARATHYROID HORMONE E D302 HEPATITIS A & B N357 WHITE CELL COUNT + DIFF E W223 WHITE CELL COUNT Only E EDTA E URINE U Y228 PROGESTERONE X548 HEPATITIS A (IgG + IgM) # OF Z229 PROLACTIN C301 HEPATITIS A, B & C (All Markers) FLUORIDE FL 24hr URINEU24 BOTTLES COAGULATION HEPARIN H OTHER F9 RENIN E G212 HEPATITIS B (Carrier) F373 ANTI-PHOSPHOLIPID Ab’s B D881 D-DIMER (Quantitative) C E SPUTUM SP E250 SOMATOMEDIN-C H306 HEPATITIS B (Immunity Only) D371 D-DIMER ( Semi-Quantitative ) C or H B231 TESTOSTERONE (F.T.I.) F304 HEPATITIS B PROFILE LUNG / KIDNEY / SKELETON LIVER / PANCREAS / GIT Z367 DIC SCREEN 1x H 2x C 2x E THYROID G305 HEPATITIS C + WEST BLOT(If positive) A115 ACE E119 ALK. PHOS. C393 FIBRINOGEN C V202 FREE T3 G121 ALPHA-1 ANTITRYPSIN F232 ALT (SGPT) W584 HEPATITIS C Only BOOK FULL BLEEDER SCREEN E349 THYROID Ab S130 CALCIUM K124 AMYLASE J307 HERPES Ab H445 INHERITED THROMBOPHILIA X204 TSH 1x on Ice E 3x C 2x E H398 ELECTROLYTES B234 AST (SGOT) J330 MEASLES Ab X158 MAGNESIUM K126 BILIRUBIN - Neonatal (SBR) S199 TSH / T4 BOOK LIMITED BLEEDER SCREEN K331 MUMPS Ab (Including Von Willebrands) B U F BILIRUBIN - Total + Conj. PREGNANCY F9 OSMOLALITY - Specify L125 2x C 1x B B S337 RUBELLA Ab K325 LUPUS ANTICOAGULANT D394 PHOSPHATE A391 CDT (Marker - Chronic Ethanol) 2x B J192 AFP Spun on Ice Spun on Ice WEIGHT X342 VARICELLA Ab C A161 POTASSIUM F143 GAMMA GT B369 PI / INR GEST AGE OTHER INFECTIONS F402 PI / INR DOSAGE - Fill in MRI no C F166 SODIUM V156 L D H B542 ANTE NATAL SCR (- HIV) BP E B D279 AMOEBIC Ab C370 PTT C J169 U & E, CREATININE U155 LFT G882 ANTE NATAL SCR (+ HIV) BP E B M287 BILHARZIA Ab BOOK THROMBOSIS SCREEN (Arterial) K170 UREA / CREATININE W157 LIPASE N196 bHCG QUANTITATIVE P289 BRUCELLA Ab T968 THROMBOSIS SCR. Venous L171 URIC ACID B162 PROTEIN ELECTROPHORESIS H260 bHCG QUALITATIVE (Pos/Neg) (With common Caucasion Mutations) GLUCOSE METABOLISM URINE / FAECAL / OTHER CHEM BONE TURNOVER W295 CYSTICERCOSIS Ab 1x E 3x C 1x B spun on ice B300 HELICOBACTER Ab F259 THROMBOSIS SCR. Venous J146 FRUCTOSAMINE/GLY. ALBUMIN W437 5HIAA U24 E120 BONE ALK. PHOS. B (Without common Caucasion Mutation) G144 GLUCOSE - Fasting FL C172 CATECHOLAMINES U24 E121 NTX CROSSLINKS U C324 LEGIONNAIRES Ab 3x C 1x B H145 GLUCOSE - Random FL M402 CREATININE CLEAR . B U24 G400 OSTEOCALCIN on ice B L332 MYCOPLASMA Ab MOLECULAR BIOLOGY PCR T407 GTT - 2hr 75g (Standard) FL P243 METANEPHRINES U24 R994 VITAMIN D spun on ice B D948 RICKETTSIAL Ab P489 PCR - HPV S L148 HbA1C/GLYCOSYLATED Hb E B288 OCCULT BLOOD - Stool AUTO IMMUNE TESTS R336 RPR ONLY Z663 PCR CHLAMYDIA PNEUM S F235 PCR CHLAMYDIA TRACH U S F246 LACTATE on ice FL F9 PORPHYRINS Quant. Sample in FOIL G282 ANCA(ANTI-NEUT.CYTOPL. Ab) T338 STD PROFILE (With HIV) B U PLEASE SPECIFY: B U F C756 PCR CMV Qualitative Csf U E K958 MICROALBUMIN - Urine U H283 ANF / DNA X504 STD PROFILE (Without HIV) B U C367 PCR CMV Quant (V.Load) Csf U E R900 PORPHYRINS Screen. FOIL U E F F348 ANF Only LIPID METABOLISM Y343 SYPHILIS SEROLOGY P128 PCR CYSTIC FIBROSIS E U132 CHOLESTEROL U247 PROTEIN U24 W593 ANTI - CCP U339 TMX (Typhoid) F430 PCR HAEMOCHROMATOSIS E W965 SEROTONIN - Plasma on ice 2x E H584 ANTI - DNA V133 CHOLESTEROL / HDL V340 TOXOPLASMA Ab W487 PCR HEP B (Qualitative) E C164 VMA / HVA U24 F373 ANTI-PHOSPHOLIPID Ab’s X135 LIPOGRAM TUMOUR MARKERS K561 PCR HEP B Quant (V.Load) E 2x B E G167 TRIGLYCERIDES IMMUNOLOGY J284 ARTHRITIS PROFILE E395 PCR HEP C (Qualitative) E Z137 C3 / C4 L192 AFP K285 ASOT / DNASE B Z352 PCR HEP C GENOTYPE E HEART / MUSCLE N288 B2 MICROGLOBULIN B139 CRP F9 AUTOIMMUNE SCREEN 2x B E P140 PCR HEP C Quant (V.Load) E F9 CHEST PAIN PROFILE P151 IgG SUBFRACTIONS A322 HLA B27 E X432 bHCG QUANTITATIVE X484 PCR MALARIA (P. falciparum) E V142 CK B N150 IMMUNOGLOBULINS N334 RHEUMATOID FACTOR M195 CA 125 (Ovary) M232 PCR MYCOPLASMA PNEUM E F9 CKMB E475 PROCALCITONIN K193 CA 153 (Breast) C232 PCR TB SP SPECIAL ALLERGY P129 HOMOCYSTEINE - Fasting on ice E T895 QUANTIFERON-TB GOLD ( TUBES ( F9 FX5 (FOOD SCREEN) D119 CA 199 F440 PCR TICK BITE FEVER E K400 MYOGLOBIN H PHARMACOLOGY C256 IgE S443 CA 724 MICROBIOLOGY B R175 CARBAMAZEPINE W354 ProBNP RAST INDIVIDUAL ALLERGENS C118 CEA B260 BLOOD CULTURE (AEROBIC-02) S176 DIGOXIN (Please specify under “other tests”) F9 TROPONIN T QUANT QUAL H P452 FREE LIGHT CHAINS on Ice B BLOOD CULTURE (OTHERS) PLEASE M471 DRUGS OF ABUSE SCREEN U B254 PHADIOTOP SPECIFY X284 ULTRASENSITIVE CRP B F121 PSA - Complexed 02 x 1 An02 02+ANO2 F189 EPILIM (VALPROIC ACID) ANDROLOGY F428 H426 Z624 IRON STUDIES B117 PSA (+Free PSA if TOTAL 2.6-10) PAED FUNG TB H F410 ETHANOL (ALCOHOL) POST VASECTOMY D141 FERRITIN H100 PSA Only (Monitoring) Z425 D848 M260 W180 LITHIUM B277 C DIFFICILE (Stool) F R152 IRON PROFILE ROUTINE SEMEN ANALYSIS Z794 SQUAMOUS CELL CARCINOMA X181 PARACETAMOL Z533 CRYPTOSPORIDIUM F Y182 PHENOBARBITONE MICROBIOLOGY K406 FUNGI MICRO + CULTURE NUTRITION SPECIALISED SERVICES AVAILABLE BY PLEASE SPECIFY C163 FOLATE (Serum + RBC) E + B Z183 PHENYTOIN APPOINTMENT ONLY. CONTACT NUMBERS: F9 MC & S F432 TB (ZN AFB - MICRO ONLY) PLEASE SPECIFY H482 SIROLIMUS LEVELS E OFFICE HOURS: (012) 664 8596 F9 MICROSCOPY ONLY L407 TB (AFB + CULTURE +/- PCR) F144 VIT B 12 SR. NIKKI HEPTON: 083 302 1048 L470 TOXICOLOGY SCREEN ALTA KOCH: 083 277 9229 SPECIMEN SITE LANCET DESK TOP PUBLISHING JHB 0027 11 358-0798 FORM NO. G0070 Z:/CDDRAW3 BLACK/FORMS/UNIVERSAL FORMS/2010/G0070 LANCET UNIVERSAL ENG BLACK DEC 2010.CDR SWITCHBOARD : 358-0800 LANCET MAIN LABORATORY *24 HOUR CLIENT SERVICES : 358-0888 ACCOUNT QUERIES : 358-0875 CNR MENTON & STANLEY RDS, RICHMOND EMERGENCY SERVICE SISTER’S DEPOT : 358-0836/7 LANCET CORNER: CLINTON HOSPITAL: JOHANNESBURG CENTRAL: MIDDLEBURG: PARKTOWN: SPRINGS: *CNR MENTON & STANLEY RDS 1st Floor Oncology Block LISTER BUILDING CNR JOUBERT & CROCKER STREETS PARKLANE CLINIC DR BRENDA WATSON'S ROOMS RICHMOND, GROUND FLOOR CNR CLINTON & PADSTOW STR., ALBERTON GROUND FLOOR,195 JEPPE STREET TEL:(013) 282-5595 FAX:(013) 282-0871 1ST FLOOR, SOUTH WING CLOVERFIELD STR., DERSLEY PARK TEL: (011) 358-0836 TEL: (011) 724 - 0600 TEL:(011) 337-2021 or (011)333-7019 WEEKDAYS: SATURDAYS: JUNCTION ROAD, PARKTOWN WEEKDAYS: 08H00 - 17H00 WEEKDAYS: SATURDAYS: WEEKDAYS: 07:00 - 17:00 WEEKDAYS: SATURDAYS: 07:00 - 19:00 07:00 - 13:00 TEL:(011) 643-5727 FAX:(011) 643-8002 SAT: 08H00 - 11H00 CLOSED ON W/ENDS & PUBLIC HOLIDAYS 07:00 - 19:00 07:00 - 13:00 07:00 - 18:00 07:00 - 15:00 MIDRAND: MON - SUN: 07:00 - 19:00 TEL: (011) 366-1222 ACTONVILLE: PUBLIC HOLIDAYS DERSLEY PARK: POLOKWANE: KENSINGTON: * CARSTENHOF CLINIC PARKLANDS CLINIC ACTONVILLE HOSPITAL C/O DR A V D MERWES ROOMS KENSINGTON CENTRE CNR DANE & ALLANDALE ROADS ARTEMIS ROAD, POLLACK PARK 2ND FLOOR, 1522 SOMA STREET CLOVERFIELD ROAD, DERSLEY PARK 44A GROBLER ST.
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