PATIENT DETAILS  
 <<Patient Demographics:Record Number>> <<Patient Demographics:DOB>><<Patient Demographics:Gender>>
<<Patient Demographics:Surname>>  <<Patient Demographics:First Name>>
<<Patient Demographics:Address Line 1>><<Patient Demographics:Address Line 2>>
<<Patient Demographics:City>> <<Patient Demographics:Postcode>> <<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 Practitionersdetermines that  Pathologists determinable tests are necessary.	
CLINICAL NOTES (include medication details e.g. current antibiotics)

	
Your doctor has recomended that uou use SYDNEY SOUTH WEST PATHOLOGY SERVICE located at:
Level 5 Royal Prince Alfred Hospital- Mon to Fri 7 am to 3:20 pm ( Tele: 9515 8695)
Suite 317, RPAH Medical Centre, 100 Carillon Avenue, Newtown- Mon to Fri 7:15am to 5:45pm (tele 9515 8840)	
REQUESTING PRACTITIONER DETAILS
<<Doctor:Name>>                              Initials:
<<Doctor:Full Address>>

<<Doctor:Phone>>
<<Doctor:Prescriber Number>>
SIGNATURE                                   <<Doctor:Fax>>
<<Miscellaneous:Date>> 
Attendinfg 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                                   <<Miscellaneous:Date>>      
PRACTITIONERS USE ONLY
(Reason patient cannot sign)                 <<Patient Demographics:Medicare Number>>
 A private patient in a private hospital, or approved day hospital facility    A public patient in a recognised hospital
  An outpatient of recognised hospital         A private patient  in a recognised hospital

Privacy Note The information provided will be used to assess any Medicare benefit payable for the services rendered and to facilitate the proper administration of government health programs, and may be used to update enrolment 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 this claim, or as authorised /required by law. 
Collection Date                         Time:                     COLLECTOR'S SIGNATURE	

EDTA

	CIT	PLAIN	HEP	FLUOR	P/YEDTA	URINE SPOT 24 HR EM

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