Human Req.form R5

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Human Req.form R5 Powered By Docstoc
					                               MOLECULAR DIAGNOSTIC SERVICES (PTY) LTD                                                                                                                    MDS REF No

                                6 Ribston Place, Westville, 3629, Pvt.Bag X20, Westville, 3630, South Africa
                                Tel: +27 31 267 7000 , Fax: +27 31 267 7005, Email:
                                VAT Reg. No. 4270210554, Practice No:0235660
                                Registration Number 2001 001779 07

 PATIENT DETAILS                                                                                                * PERSON RESPONSIBLE FOR PAYMENT OF ACCOUNT
 REFERRING DOCTOR                                                                                          SURNAME:
 TEL                                                 CELL                                                  FIRST NAMES:
 COPY DOCTORS                                                                                              *ID NO
 HOSPITAL                                                           WARD                                   POSTAL ADDRESS:

FIRST NAMES                                                                                                TEL W                                      TEL H                                   CELL
ID No                                                                                                      Email
 TEL                                         CELL                                                          Employer:
HOSP PAT             Y     N SEX M F                   REF/FILE No                                         MED AID:                                                     AUTHORISATION NO
 SPECIMEN TYPE                                                                                             MED AID No:                                                  DEPENDANT CODE
                                                                                                           I consent to tests requested, guarantee payment
 COLLECTION DATE:                                    TIME:                      BY:                        and verify that all information is correct

                                                                                                           I hereby give consent that the laboratory is allowed to release
 ICD 10 CODES                                                                                              the diagnostic codes to my Medical aid        [Yes] [Refused]

        PAYMENT DETAILS (The patient is required to make upfront payment directly to MDS if not submitting through their own medical aid)

 DIRECT DEPOSIT                                      CASH           CHEQUE                   CREDIT CARD
 Banking Details :                                   CVV
 FNB, Westville Branch,
 Branch Code : 223526                                EXP.       /         Name on Card :
 Account No : 62109297912                            We accept Visa, Master Card and American Express Cards
( Please indicate the test you require by making a X )
        CENTRAL NERVOUS SYSTEM                                     CLINICAL INFORMATION                                    UROGENITAL                                                  RESPIRATORY
        ADENOVIRUS                                     Clinical Information :                                              ADENOVIRUS                                                  ADENOVIRUS
        BARTONELLA SPP.                                                                                                    ACANTHAMOEBA SPP.                                           BORDETELLA BRONCHISEPTICA
        BORRELIA BURGDORFERII                                                                                              BK VIRUS                                                    BORDETELLA PARAPERTUSSIS
        CYTOMEGALOVIRUS                                                                                                    CHLAMYDIA TRACHOMATIS                                       BORDETELLA PERTUSSIS
        ENTEROVIRUS                                                                                                        CYTOMEGALOVIRUS                                             CHLAMYDOPHILA PNEUMONIAE
        EPSTEIN BARR VIRUS                             Other Tests : (We are constantly developing new tests,              GARDNERELLA VAGINALIS
                                                                                                                                                                                       CHLAMYDOPHILA PSITTACI
        HERPES SIMPLEX VIRUS (1&2)                     so please contact us with any requests)                             HAEMOPHILUS DUCREYI
        HIV                                                                                                                HERPES SIMPLEX VIRUS (1&2)
        JC VIRUS                                                                                                           HUMAN PAPILLOMA VIRUS DETECTION
        LEPTOSPIRA SPP.                                        EXANTHEMS                                                   HUMAN PAPILLOMA VIRUS GENOTYPING
                                                               BARTONELLA SPP.                                             JC VIRUS                                                    HAEMOPHILUS INFLUENZAE
        MEASLES                                                BORRELIA BURGDORFERII                                       MYCOBACTERIUM TUBERCULOSIS                                  HERPES SIMPLEX VIRUS
        MUMPS                                                  ENTEROVIRUS                                                 MYCOPLASMA SPP.                                             HUMAN METAPNEUMOVIRUS
        MYCOBACTERIUM TUBERCULOSIS                             EPSTEIN BARR VIRUS                                          NEISSERIA GONORRHOEAE                                       INFLUENZA A
        NEISSERIA MENINGITIDIS                                 HERPES SIMPLEX VIRUS (1&2)                                  TREPONEMA PALLIDUM                                          INFLUENZA B
        TOXOPLASMA GONDII                                      HHV-8                                                       TRICHOMONAS VAGINALIS                                       LEGIONELLA MICDADEI
        VARICELLA ZOSTER VIRUS                                 MEASLES                                                     GASTROINTESTINAL                                            LEGIONELLA PNEUMOPHILA
        BLOOD-BORNE PATHOGENS                                  MYCOBACTERIUM TUBERCULOSIS                                  ADENOVIRUS                                                  MYCOBACTERIUM AVIUM
        BABESIA SPP.                                           PARVOVIRUS B19                                              CRYPTOSPORIDIUM SPP.                                        MYCOBACTERIUM TUBERCULOSIS (MTB)
        BORRELIA BURGDORFERII                                  RUBELLA                                                     E.COLI (TOXINS: stx I, II)                                  MYCOBACTERIUM SPP.
        EPSTEIN BARR VIRUS                                     TREPONEMA PALLIDUM                                          E.COLI (VIRULENCE FACTORS: eaeA, hlyA)                      MTB DRUG RESISTANCE
        HHV-8                                                  VARICELLA ZOSTER VIRUS                                      E.COLI 0157 / H7                                            MYCOPLASMA PNEUMONIAE
        LEPTOSPIRA SPP.                                        CARDIAC                                                     ENTEROVIRUS
                                                                                                                                                                                       PARAINFLUENZA VIRUS 1-4
        MALARIA DETECTION                                      CHLAMYDOPHILA PNEUMONIAE                                    HELICOBACTER PYLORI
                                                                                                                                                                                       PNEUMOCYSTIS JIROVECI
        MALARIA TYPING                                         CYTOMEGALOVIRUS                                             ROTAVIRUS
                                                                                                                                                                                       RESPIRATORY SYNCYTIAL VIRUS
        MEASLES                                                ENTEROVIRUS                                                 SALMONELLA SPP.
                                                                                                                                                                                       STREPTOCOCCUS PNEUMONIAE
        MUMPS                                                  HAEMOPHILUS INFLUENZAE                                      OCULAR
                                                               MYCOPLASMA PNEUMONIAE                                       ACANTHAMOEBA SPP.                                           STREPTOCOCCUS PYOGENES
        PARVOVIRUS B19
        RUBELLA                                                RUBELLA                                                     ADENOVIRUS                                                  HIV
        HEPATITIS                                              ENT                                                         CHLAMYDIA TRACHOMATIS                                       CD4
        HEPATITIS A VIRUS                                      HAEMOPHILUS INFLUENZAE                                      CYTOMEGALOVIRUS                                             HIV RNA
        HEPATITIS B VIRUS                                      MORAXELLA CATARRHALIS                                       ENTEROVIRUS                                                 HIV VIRAL LOAD
        HEPATITIS C VIRUS                                      MUMPS                                                       HERPES VIRUS (1&2)                                          HIV DRUG RESISTANCE

 Central Nervous System   CSF                           Exanthems     Lesion swab                                 Urogenital       Urine, urethral swab, vaginal /           Respiratory Respiratory swab, sputum, BAL, ETA
 Blood-borne Pathogens    EDTA whole blood              Cardiac       Urine, faeces, biopsy                                        cervical swab                             Hepatitis   EDTA whole blood, plasma, serum
 HIV                      EDTA whole blood, plasma      ENT           Nasopharyngeal swab, ear swab               Gastrointestinal Faeces, faecal swab
                                                                                                                  Ocular           Eye swab, eye wash, biopsy

                                                                                                                                                                                                            Form ADM RQT-0021-1

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