PATIENT DETAILS  Patient Identifier <PtRecordNo>            <PtDoB>                  <PtSex>

<PtSurname><PtSurname>                                                   <PtFirstName>
<PtStreet>
<PtCity>                                                 <PtPostcode>                      <Ward/Clinic> 
Account Address (if different from above)
	
TESTS REQUESTED                                            URGENT: YES/NO      FASTING: YES/NO

FIRST TRIMESTER COMBINED SCREENING

 “ SD(Self Determined) used when approved Pathology Practitioner determines that Pathologist determinable tests are necessary	
CLINICAL NOTES (include medication details e.g.current antibiotics)

	
Your Doctor suggested that you use SYDNEY SOUTH WEST PATHOLOGY SERVICE located at:
Level 5, royal Prince Alfred Hospital- Mon to Fri 7am to 3:20pm (Tele: 9515 8695)
Suite 317, RPAH Medical Centre,100 Crillon Avenue, Newtown-Mon to Fri 7:15am to 5:45pm (Tele: 95158840)	
REQUESTING PRACTITIONER DETAILS 
<DrSurname>                                            Intials
<DrAddress>
                                                                <DrPhone>
<DrProviderNo>
SIGNATURE                                    <DrFax>

<DayAndDate>                   Attending Medical Officer

MEDICARE ASSIGNMENT (Section20A of Health Insurance Act 1973) - to be completed by the pateint offering to assign benefits for services on this form. 
I offer to assign my righto enefits to the approved pathology practitioner who will render he requested pathology dervice(s) and any eligible pathologist determinable servicce(s) established as ecessary by the practitioner

PATIENT'S SIGNATURE                                                                  <DayAndDate>
PRACTITIONER USE ONLY
(reason patientcannot sign)                                       MEDICARE NUMBER: <PtMCNo>
PATIENT STATUS at the time of the service or specimen collection:
 A private patient in a private hospital, or approved day hospital facility   A public patient in a recogised hospital
 An outpatient of a recognised hospital    A private patient in a recognised hospital

Privacy Note: The information provided to assess any Medicare benefit payable for the services rendered and to facilitate the proper administration of goernmentnhealth programs, and may be used to update enro;ement records. Its collection is authorised by provisions of the Health Insurance Act 1973. The information may be disclosed to the Department of Health and Ageing or to a person in the medical practice associated with the claim, or as authorised/required by law.

COLLECTION DATE:             /     /             TIME:               COLLECTOR'S SIGNATURE:
	
EDTA

	CIT	PLAIN	HEP	FLUOR	P/Y EDTA	URINE SPOT 24 HR EM

	CSF	FAECES SPOT 3 DAY	SWAB	SPUTUM	BC	SLIDE	HIST  FORMALIN FRESH	OTHER	CHECKED BY