COMBINED PATHOLOGY 
GP REQUEST FORM	
NHS

Barking Havering & Redbridge Hospitals 
                                                    NHS Trust                                           	
FILL IN YOUR DETAILS (minimum Surname, Forename, DoB, Gender and Address) 

NHS No.  
Surname:  
Forenames: 
Address: 

Tel:   

Sex:                                     D.o.B: 	Western Road Medical Centre 

	
Drop No.  

102C2	
Relevant clinical details:      Hypertension monitoring              

Date:	01-Sep-2020 
Time:	11:06am 	Specimen Type:  FASTING BLOOD TEST  / NON-FASTING BLOOD TEST x     / MSU  / CSU  / Faeces  / HVS  / wound swab  / Urine  /  other      	NHS   	
		Private 	
BIOCHEMISTRY	HAEMATOLOGY	IMMUNOLOGY	MICROBIOLOGY	
x	U & E							

								

							

					

					

					

	For laboratory use only:	Please note:  Tests for viral studies, rubella, serology Or HIV testing require a specific, separate form

*INSTRUCTIONS FOR PATIENTS – IMPORTANT – PLEASE READ*

1.	Please print the form, fill in you details at the top of the form and take it to the blood test centre
2.	You must book a blood test centre appointment using the link “Book Online” on our home page westernroad.co.uk
OR call 03003001704 OR use this link https://10to8.com/book/nelftbookabloodtest/
      Children under age of 12 years – call 01708 435289 to book a blood test appointment
3.	If indicated above, the instructions for fasting are: Nothing to eat from 10pm until after the blood test has been taken. Only water and normal medication should be taken.