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Medical Laboratory
Chemistry Test - Lab Request Form
Patient & Referral Physician Information
Your Name
Sex
Male
Female
Date Of Birth
Phone Number
Name Of Referral Hosp/Clinic
Name Of Physician
Email Address
Today's Date
Today's Date
Emergency (Within An Hour)
Urgent (Within 24 Hours)
Within 7 Days
Select Lab Tests Required
Fasting Blood Sugar
Random Blood Sugar
Total Bilirubin
Gamma GT
Direct Bilirubin
Indirect Bilirubin
S.G.O.T (AST)
S.G.P.T (ALT)
Alkaline Phosphatase
Total Proteins
Albumin
Globulin
Hepatitis B (Hbs Ag)
Urea
Creatinine
Sodium
Potassium
Chloride
Cholesterol
Triglycerides
HDL Cholesterol
LDL Cholesterol
Uric Acid
LDH
C.P.K.
Amylase
Calcium
Other Test (Specify)
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