Please complete all elements of the request card. Affixing a self-adhesive label containing patient information is acceptable.
To avoid unnecessary follow-up calls for missing information, please ensure that the following minimum data is provided.

• Patient First Name
• Patient Last Name
• Date of Birth
• Address (inc Postcode)
• Unit number/ NHS number
• Clinical Information
• Test(s) required
• Referring Consultant
• Referring Unit details
• Date of sampling
• Indication if consent to store clinical material is declined.

Revised 18.05.04 (Alan Clark)
Authorised 23.06.04 (Peter Howard)