Client Medicals Request

Client Name:
Client Surname:
Gender: Male Female


Identity/Passport Number:
Propsal/Policy Number:
Address:
Contact no1:
Contact no2:
Broker Consultant Email:
Broker Email:
Important information for Nurses attention: eg. Fear of needles, call after 15:00 etc.

Chemistry

ALBUMIN
ALKALINE PHOSPHATASE
ALT
AST
BILIRUBIN (total only)
CDT
CHOLESTEROL (only) (FastingYes No)
CREATININE
FRUCTOSAMINE
GAMMA-GT
GGT+ ALT+ AST( liver functions)
GLUCOSE (FastingYes No)
GTT 2HR (glucose tolerance test)
HbA1c
HDL (FastingYes No)
HDL + CHOLESTEROL (FastingYes No)
LIPOGRAM (FastingYes No)
TOTAL PROTEIN
TRIGLYCERIDES (FastingYes No)
UREA
URIC ACID

Haematology

ESR
FULL BLOOD COUNT (only)
HB (only)
MCV
PCV (only)

Microbiology

CHEMICAL + MICROSCOPIC URINALYSIS
LAB URINE DIPSTICK
CANNABIS
COCAINE
MICROALBUMIN : CREATININE RATIO

Serology

COTININE
HIV (Elisa)
HIV + COTININE
RPR (VDRL only)
TREPONEMA PALLIDIUM IgG
TOTAL PSA
OTHER TESTS

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