Agilus Diagnostics

Agilus Diagnostics FZ-LLC

www.agilusdiagnostics.ae
Email: helpdesk@srlworld.com
Phone: +971-44483100 | Fax: +971-44484694
Al Razi,Building 64, Unit 1007, 1018 & 1019
Dubai Healthcare City, Dubai, P.O. Box: 505143

Specimen Pickup Helpline(for UAE clients only):04-4483100

For Office use only

Date

Time

AWB

Clinical Pathology Test Requistion Form

Patient First Name

Last Name

Date of Birth

Age

Nationality

Weightkg

Heightcm

Patient Hosp Id

GenderM F

Client Name

Code

Email

Telephone

Please click in any of the boxes below to select a test from Agilus menu or write its name

Sample Collection

Date & Time

Speciman Type

CSF	A	F	C
Urine	A	F	C
Serum	A	F	C
Fluid	A	F	C
Plasma EDTA	A	F	C
Plasma FL	A	F	C
FN Aspirate	A	F	C
W.Blood EDTA	A	F	C
W.Blood FL	A	F	C
W.Blood HEP	A	F	C
W.Blood ACD	A	F	C
W.Blood sodium Citrate	A	F	C
Sputum	A	F	C
Filter Paper	A	F	C
Smear	A	F	C
Stool	A	F	C
Swab	A	F	C

F:Frozen(<-10⁰c)

C:Cold(2⁰-8⁰C)

A:Ambient

Other Tests

Patient's Signature

Doctor's Signature

Date

Click here to access the Test menu