Monash Universityusers.monash.edu/~roset/thesis/chapt3/fig3.2-5.pdf · Monash University
Monash SOUTHERN CROSS PATHOLOGYAUSTRALIA Pathology ...
2
Patient status at the time of the service Yes No or when the specimen was collected. (a) a private patient in a private hospital or approved day hospital facility (b) a private patient in a recognised hospital (c) a public patient in a recognised hospital (d) an outpatient of a recognised hospital NATA SPECIMEN TYPE: BLOOD URINE OTHER ...................................... I certify that I collected the specimen accompanying this request from the stated patient whose details I confirmed by direct enquiry and/or examination of their ID wristband and I labelled the specimen immediately after collection in the presence of the patient. SIGNED: .......................... Print SURNAME: ................................................ Date: ........../........../......... Time: ................. hour Laboratory use only Your treating practitioner has recommended that you use Monash Pathology. You are free to choose your own pathology provider. However, if your treating practitioner has specified a particular pathologist on clinical grounds, a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your treating practitioner. TESTS REQUESTED Paediatric samples- list tests in order of priority. ANTIBIOTIC: .................................. Spot Dose: .......................... mg Frequency: daily BD Other ............................. START administration ......../......../........ ............ hour FINISH administration ........./......../........ ............ hour FIRST SAMPLE/SPOT ........./......../........ ............ hour SECOND SAMPLE ......../......../........ ............ hour Doctor’s NAME (print) ........................................................... Sign ............................................. Date ..................... Pager ....................... Phone ............................... Fax ................................ REQUESTING PRACTITIONER Provider number: ................................................................................. SURNAME & FIRST NAME: ............................................................. ADDRESS: .......................................................................................... ............................................................................................................... PATIENT DETAILS UR SURNAME ............................................................................................ GIVEN NAMES ..................................................................................... DOB ....... / ....... / ....... WARD .................. GENDER . ............... ADDRESS.............................................................................................. ................................................................................................................. ................................................................................................................. Identify Request Situation Background Assessment CLINICAL DETAILS Self Determined Fasting: OCP: HRT: Pregnant: Gestation: ................... Medication: ................. ..................................... Dosage: ...................... Time: ........................... Histopathology - list previous biopsies including laboratory numbers Medicare number I offer to assign my right to benefits to the approved pathology practitioner who will render the requested pathology service(s) and any eligible pathologist determinable service(s) established as necessary by the practitioner. .......................................................... ....... /...... /....... Patient’s signature Date PRACTITIONERS USE ONLY ....................................................................... (Reason patient cannot sign) MonashPathology MonashHealth (APA) Urgent – contact laboratory to prioritise. Precious/irreplaceable specimen requiring confirm receipt on Phone/Pager: ........................... Pathology Request Form Telephone 03 9594 4538 Facsimile 03 9594 6619 Accredited for compliance with NPAAC standards and ISO 15189 Accredited for Expiry date ...... /...... COPY TO Provider number: ....................................................................... SURNAME & FIRST NAME: ................................................... ADDRESS: ................................................................................ .....................................................................................................
Transcript of Monash SOUTHERN CROSS PATHOLOGYAUSTRALIA Pathology ...
Patient status at the time of the service Yes No or when the specimen was collected. (a) a private patient in a private hospital
or approved day hospital facility(b) a private patient in a recognised hospital
(c) a public patient in a recognised hospital
(d) an outpatient of a recognised hospital
SOUTHERN CROSS PATHOLOGY AUSTRALIA
SOUTHERN CROSS PATHOLOGY AUSTRALIA
Southern Health APA 246 Clayton Road Clayton 3168
Southern Health APA 246 Clayton Road Clayton 3168
PATIENT DETAILS
PATIENT DETAILS
REQUESTING PRACTITIONER DETAILS
REQUESTING PRACTITIONER DETAILS
COPYTO:
COPYTO:
TESTS REQUESTED: (for blood bank requests see reverse also)
TESTS REQUESTED: (for blood bank requests see reverse also)
SELF DETERMINE
SELF DETERMINE
REPORT DESTINATION
REPORT DESTINATION
DOCTOR'SSIGNATURE
DOCTOR'SSIGNATURE
X
X
or OP Clinic No:
or OP Clinic No:
UR
UR
SURNAME
GIVEN NAMES
ADDRESS
SURNAME
GIVEN NAMES
ADDRESS
SURNAME & INITIALS
ADDRESS
SURNAME & INITIALS
ADDRESS
I offer to assign my right to benefits to the approved pathology practitioner who willrender the requested pathology service(s) and any eligible pathologist determinableservice(s) established as necessary by the practitioner.
I offer to assign my right to benefits to the approved pathology practitioner who willrender the requested pathology service(s) and any eligible pathologist determinableservice(s) established as necessary by the practitioner.
Medicare number
Medicare number
Practitioner’s use only
Practitioner’s use only
(reason patient cannot sign)
(reason patient cannot sign)
Provider number
Provider number
Date of Request
Date of Request
Patient status at the time of the service or when thespecimen was collected:
Patient status at the time of the service or when thespecimen was collected:
(a) a private patient in a private hospitalor approved day hospital facility
(a) a private patient in a private hospitalor approved day hospital facility
(b) a private patient in a recognised hospital
(b) a private patient in a recognised hospital
(c) a public patient in a recognised hospital
(c) a public patient in a recognised hospital
(d) an outpatient of a recognised hospital
(d) an outpatient of a recognised hospital
Yes
Yes
No
No
SST LH FL ED CT ACD SY OT
/ /
/ /
CYTOLOGY REQUESTS
CYTOLOGY REQUESTS
BLOOD BANK REQUESTS
BLOOD BANK REQUESTS
SPECIMENTYPE:
SPECIMENTYPE:
INDICATIONS FORTEST
INDICATIONS FORTEST
SEX DOB / /
SEX DOB / /
PREGNANT
Weeks Gestation
PREGNANT
Weeks Gestation
Past Tx
Past Pregnancy
Past Tx
Past Pregnancy
Site of Tx
Date of Tx
Site of Tx
Date of Tx
BLOOD
BLOOD
URINE
URINE
OTHER
OTHERI certify that the pathology specimen accompanying the request was drawnfrom the patient stated above as established by direct inquiry and/or wrist bandand labelled immediately.
SIGNED
SIGNED
person collecting sample
person collecting sample
specimen date & time
specimen date & time
/ /
/ /
Urgent
Urgent
Phone
Fax
Phone
Fax
Pager No
Date
Pager No
Date
HRT
HRT
OCP
OCP
PLEASE USE DESIGNATED FORM FORBLOOD BANK REQUEST
PLEASE USE DESIGNATED FORM FORBLOOD BANK REQUEST
LABUSE
LABUSE
x
x
Patient's signature
Patient's signature
DATE
DATE
EXPIRY DATE
EXPIRY DATE
/ /
/ /
/ /
/ /
Pathology Request FormTelephone 03 9594 4538 Facsimile 03 9594 6619
NATA
Pathology Request FormTelephone 03 9594 4538 Facsimile 03 9594 6619 A/4198
NATAAccredited for compliancewith AS 4633 (ISO 15189)
SPECIMEN TYPE: BLOOD URINE OTHER ......................................I certify that I collected the specimen accompanying this request from the stated patient whose details I confirmed by direct enquiry and/or examination of their ID wristband and I labelled the specimen immediately after collection in the presence of the patient.SIGNED: .......................... Print SURNAME: ................................................ Date: ........../........../......... Time: ................. hour
Laboratory use only
Your treating practitioner has recommended that you use Monash Pathology. You are free to choose your own pathology provider.However, if your treating practitioner has specified a particular pathologist on clinical grounds, a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your treating practitioner.
TESTS REQUESTED Paediatric samples- list tests in order of priority.
ANTIBIOTIC: .................................. Spot
Dose: .......................... mg
Frequency: daily BD Other .............................
START administration ......../......../........ ............ hour
FINISH administration ........./......../........ ............ hour
FIRST SAMPLE/SPOT ........./......../........ ............ hour
SECOND SAMPLE ......../......../........ ............ hourDoctor’s NAME (print) ........................................................... Sign ............................................. Date ..................... Pager ....................... Phone ............................... Fax ................................
REQUESTING PRACTITIONER Provider number: .................................................................................SURNAME & FIRST NAME: .............................................................ADDRESS: .........................................................................................................................................................................................................
PATIENT DETAILS UR
SURNAME ............................................................................................
GIVEN NAMES .....................................................................................
DOB ....... / ....... / ....... WARD .................. GENDER ................
ADDRESS ..............................................................................................
.................................................................................................................
.................................................................................................................
IdentifyR
equestSituation Background Assessm
ent
CLINICAL DETAILS Self Determined Fasting: OCP: HRT: Pregnant: Gestation: ...................Medication: ................. .....................................Dosage: ......................Time: ...........................
Histopathology - list previous biopsies including laboratory numbers
Medicare number I offer to assign my right to benefits to the approved pathology practitioner who will render the requested pathology service(s) and any eligible pathologist determinable service(s) established as necessary by the practitioner.
.......................................................... ....... /...... /.......Patient’s signature Date
PRACTITIONERS USE ONLY....................................................................... (Reason patient cannot sign)
MonashPathologyMonashHealth (APA)
Urgent – contact laboratory to prioritise. Precious/irreplaceable specimen requiring confirm receipt on Phone/Pager: ...........................
Pathology Request FormTelephone 03 9594 4538 Facsimile 03 9594 6619
Accredited for compliance with NPAAC standards and ISO 15189
SOUTHERN CROSS PATHOLOGY AUSTRALIA
SOUTHERN CROSS PATHOLOGY AUSTRALIA
Southern Health APA 246 Clayton Road Clayton 3168
Southern Health APA 246 Clayton Road Clayton 3168
PATIENT DETAILS
PATIENT DETAILS
REQUESTING PRACTITIONER DETAILS
REQUESTING PRACTITIONER DETAILS
COPYTO:
COPYTO:
TESTS REQUESTED: (for blood bank requests see reverse also)
TESTS REQUESTED: (for blood bank requests see reverse also)
SELF DETERMINE
SELF DETERMINE
REPORT DESTINATION
REPORT DESTINATION
DOCTOR'SSIGNATURE
DOCTOR'SSIGNATURE
X
X
or OP Clinic No:
or OP Clinic No:
UR
UR
SURNAME
GIVEN NAMES
ADDRESS
SURNAME
GIVEN NAMES
ADDRESS
SURNAME & INITIALS
ADDRESS
SURNAME & INITIALS
ADDRESS
I offer to assign my right to benefits to the approved pathology practitioner who willrender the requested pathology service(s) and any eligible pathologist determinableservice(s) established as necessary by the practitioner.
I offer to assign my right to benefits to the approved pathology practitioner who willrender the requested pathology service(s) and any eligible pathologist determinableservice(s) established as necessary by the practitioner.
Medicare number
Medicare number
Practitioner’s use only
Practitioner’s use only
(reason patient cannot sign)
(reason patient cannot sign)
Provider number
Provider number
Date of Request
Date of Request
Patient status at the time of the service orwhen the specimen was collected:
Patient status at the time of the service orwhen the specimen was collected:
(a) a private patient in a private hospitalor approved day hospital facility
(b) a private patient in a recognised hospital
(c) a public patient in a recognised hospital
(d) an outpatient of a recognised hospital
(a) a private patient in a private hospitalor approved day hospital facility
(b) a private patient in a recognised hospital
(c) a public patient in a recognised hospital
(d) an outpatient of a recognised hospital
Yes
Yes
No
No
SST LH FL ED CT ACD SY OT
/ /
/ /
CYTOLOGY REQUESTS
CYTOLOGY REQUESTS
BLOOD BANK REQUESTS
BLOOD BANK REQUESTS
SPECIMENTYPE:
SPECIMENTYPE:
INDICATIONS FORTEST
INDICATIONS FORTEST
SEX DOB / /
SEX DOB / /
PREGNANT
Weeks Gestation
PREGNANT
Weeks Gestation
Past Tx
Past Pregnancy
Past Tx
Past Pregnancy
Site of Tx
Date of Tx
Site of Tx
Date of Tx
BLOOD
BLOOD
URINE
URINE
OTHER
OTHER
I certify that the pathology specimen accompanying the request was drawnfrom the patient stated above as established by direct inquiry and/or wrist bandand labelled immediately.
I certify that the pathology specimen accompanying the request was drawnfrom the patient stated above as established by direct inquiry and/or wrist bandand labelled immediately.
SIGNED
SIGNED
person collecting sample
person collecting sample
specimen date & time
specimen date & time
/ /
/ /
Urgent
Urgent
Phone
Fax
Phone
Fax
Pager No
Date
Pager No
Date
HRT
HRT
OCP
OCP
PLEASE USE DESIGNATED FORM FORBLOOD BANK REQUEST
PLEASE USE DESIGNATED FORM FORBLOOD BANK REQUEST
LABUSE
LABUSE
x
x
Patient's signature
Patient's signature
DATE
DATE
EXPIRY DATE
EXPIRY DATE
/ /
/ /
/ /
/ /
Pathology Request FormTelephone 03 9594 4538 Facsimile 03 9594 6619 A/4197
NATAAccredited for compliancewith AS 4633 (ISO 15189)
Pathology Request FormTelephone 03 9594 4538 Facsimile 03 9594 6619 A/4197
NATAAccredited for compliancewith AS 4633 (ISO 15189)
SOUTHERN CROSS PATHOLOGY AUSTRALIA
SOUTHERN CROSS PATHOLOGY AUSTRALIA
Southern Health APA 246 Clayton Road Clayton 3168
Southern Health APA 246 Clayton Road Clayton 3168
PATIENT DETAILS
PATIENT DETAILS
REQUESTING PRACTITIONER DETAILS
REQUESTING PRACTITIONER DETAILS
COPYTO:
COPYTO:
TESTS REQUESTED: (for blood bank requests see reverse also)
TESTS REQUESTED: (for blood bank requests see reverse also)
SELF DETERMINE
SELF DETERMINE
REPORT DESTINATION
REPORT DESTINATION
DOCTOR'SSIGNATURE
DOCTOR'SSIGNATURE
X
X
or OP Clinic No:
or OP Clinic No:
UR
UR
SURNAME
GIVEN NAMES
ADDRESS
SURNAME
GIVEN NAMES
ADDRESS
SURNAME & INITIALS
ADDRESS
SURNAME & INITIALS
ADDRESS
I offer to assign my right to benefits to the approved pathology practitioner who willrender the requested pathology service(s) and any eligible pathologist determinableservice(s) established as necessary by the practitioner.
I offer to assign my right to benefits to the approved pathology practitioner who willrender the requested pathology service(s) and any eligible pathologist determinableservice(s) established as necessary by the practitioner.
Medicare number
Medicare number
Practitioner’s use only
Practitioner’s use only
(reason patient cannot sign)
(reason patient cannot sign)
Provider number
Provider number
Date of Request
Date of Request
Patient status at the time of the service orwhen the specimen was collected:
Patient status at the time of the service orwhen the specimen was collected:
(a) a private patient in a private hospitalor approved day hospital facility
(b) a private patient in a recognised hospital
(c) a public patient in a recognised hospital
(d) an outpatient of a recognised hospital
(a) a private patient in a private hospitalor approved day hospital facility
(b) a private patient in a recognised hospital
(c) a public patient in a recognised hospital
(d) an outpatient of a recognised hospital
Yes
Yes
No
No
SST LH FL ED CT ACD SY OT
/ /
/ /
CYTOLOGY REQUESTS
CYTOLOGY REQUESTS
BLOOD BANK REQUESTS
BLOOD BANK REQUESTS
SPECIMENTYPE:
SPECIMENTYPE:
INDICATIONS FORTEST
INDICATIONS FORTEST
SEX DOB / /
SEX DOB / /
PREGNANT
Weeks Gestation
PREGNANT
Weeks Gestation
Past Tx
Past Pregnancy
Past Tx
Past Pregnancy
Site of Tx
Date of Tx
Site of Tx
Date of Tx
BLOOD
BLOOD
URINE
URINE
OTHER
OTHER
I certify that the pathology specimen accompanying the request was drawnfrom the patient stated above as established by direct inquiry and/or wrist bandand labelled immediately.
I certify that the pathology specimen accompanying the request was drawnfrom the patient stated above as established by direct inquiry and/or wrist bandand labelled immediately.
SIGNED
SIGNED
person collecting sample
person collecting sample
specimen date & time
specimen date & time
/ /
/ /
Urgent
Urgent
Phone
Fax
Phone
Fax
Pager No
Date
Pager No
Date
HRT
HRT
OCP
OCP
PLEASE USE DESIGNATED FORM FORBLOOD BANK REQUEST
PLEASE USE DESIGNATED FORM FORBLOOD BANK REQUEST
LABUSE
LABUSE
x
x
Patient's signature
Patient's signature
DATE
DATE
EXPIRY DATE
EXPIRY DATE
/ /
/ /
/ /
/ /
Pathology Request FormTelephone 03 9594 4538 Facsimile 03 9594 6619 A/4197
NATAAccredited for compliancewith AS 4633 (ISO 15189)
Pathology Request FormTelephone 03 9594 4538 Facsimile 03 9594 6619 A/4197
NATAAccredited for compliancewith AS 4633 (ISO 15189)
SOUTHERN CROSS PATHOLOGY AUSTRALIA
SOUTHERN CROSS PATHOLOGY AUSTRALIA
Southern Health APA 246 Clayton Road Clayton 3168
Southern Health APA 246 Clayton Road Clayton 3168
PATIENT DETAILS
PATIENT DETAILS
REQUESTING PRACTITIONER DETAILS
REQUESTING PRACTITIONER DETAILS
COPYTO:
COPYTO:
TESTS REQUESTED: (for blood bank requests see reverse also)
TESTS REQUESTED: (for blood bank requests see reverse also)
SELF DETERMINE
SELF DETERMINE
REPORT DESTINATION
REPORT DESTINATION
DOCTOR'SSIGNATURE
DOCTOR'SSIGNATURE
X
X
or OP Clinic No:
or OP Clinic No:
UR
UR
SURNAME
GIVEN NAMES
ADDRESS
SURNAME
GIVEN NAMES
ADDRESS
SURNAME & INITIALS
ADDRESS
SURNAME & INITIALS
ADDRESS
I offer to assign my right to benefits to the approved pathology practitioner who willrender the requested pathology service(s) and any eligible pathologist determinableservice(s) established as necessary by the practitioner.
I offer to assign my right to benefits to the approved pathology practitioner who willrender the requested pathology service(s) and any eligible pathologist determinableservice(s) established as necessary by the practitioner.
Medicare number
Medicare number
Practitioner’s use only
Practitioner’s use only
(reason patient cannot sign)
(reason patient cannot sign)
Provider number
Provider number
Date of Request
Date of Request
Patient status at the time of the service orwhen the specimen was collected:
Patient status at the time of the service orwhen the specimen was collected:
(a) a private patient in a private hospitalor approved day hospital facility
(b) a private patient in a recognised hospital
(c) a public patient in a recognised hospital
(d) an outpatient of a recognised hospital
(a) a private patient in a private hospitalor approved day hospital facility
(b) a private patient in a recognised hospital
(c) a public patient in a recognised hospital
(d) an outpatient of a recognised hospital
Yes
Yes
No
No
SST LH FL ED CT ACD SY OT
/ /
/ /
CYTOLOGY REQUESTS
CYTOLOGY REQUESTS
BLOOD BANK REQUESTS
BLOOD BANK REQUESTS
SPECIMENTYPE:
SPECIMENTYPE:
INDICATIONS FORTEST
INDICATIONS FORTEST
SEX DOB / /
SEX DOB / /
PREGNANT
Weeks Gestation
PREGNANT
Weeks Gestation
Past Tx
Past Pregnancy
Past Tx
Past Pregnancy
Site of Tx
Date of Tx
Site of Tx
Date of Tx
BLOOD
BLOOD
URINE
URINE
OTHER
OTHER
I certify that the pathology specimen accompanying the request was drawnfrom the patient stated above as established by direct inquiry and/or wrist bandand labelled immediately.
I certify that the pathology specimen accompanying the request was drawnfrom the patient stated above as established by direct inquiry and/or wrist bandand labelled immediately.
SIGNED
SIGNED
person collecting sample
person collecting sample
specimen date & time
specimen date & time
/ /
/ /
Urgent
Urgent
Phone
Fax
Phone
Fax
Pager No
Date
Pager No
Date
HRT
HRT
OCP
OCP
PLEASE USE DESIGNATED FORM FORBLOOD BANK REQUEST
PLEASE USE DESIGNATED FORM FORBLOOD BANK REQUEST
LABUSE
LABUSE
x
x
Patient's signature
Patient's signature
DATE
DATE
EXPIRY DATE
EXPIRY DATE
/ /
/ /
/ /
/ /
Pathology Request FormTelephone 03 9594 4538 Facsimile 03 9594 6619 A/4197
NATAAccredited for compliancewith AS 4633 (ISO 15189)
Pathology Request FormTelephone 03 9594 4538 Facsimile 03 9594 6619 A/4197
NATAAccredited for compliancewith AS 4633 (ISO 15189)
I certify that I collected the accompanying sample from the above patient, whose identity was confirmed by inquiry and/or examination of their name-band, and that I labelled the sample immediately following collection.
SOUTHERN CROSS PATHOLOGY AUSTRALIASouthern Health APA 246 Clayton Road Clayton 3168
PATIENT DETAILS REQUESTING PRACTITIONER DETAILS
COPYTO:
TESTS REQUESTED: (for blood bank requests see reverse also)
SELF DETERMINE
REPORT DESTINATION
DOCTOR'SSIGNATURE X
or OP Clinic No:
UR
SURNAME
GIVEN NAMES
ADDRESS
SURNAME & INITIALS
ADDRESS
I offer to assign my right to benefits to the approved pathology practitioner who willrender the requested pathology service(s) and any eligible pathologist determinableservice(s) established as necessary by the practitioner.
Medicare number
Practitioner’s use only
(reason patient cannot sign)
Provider number
Date of Request
Patient status at time of service or when thespecimen was collected
(a) A private patient in a private hospital or approvedday hospital facility
(b) A private patient in a recognised hospital
(c) A public patient in a recognised hospital
(d) An outpatient of a recognised hospital
Yes No
SST LH FL ED CT ACD SY OT/ /
CYTOLOGY REQUESTS BLOOD BANK REQUESTS
SPECIMENTYPE:
INDICATIONS FORTEST:
SEX DOB / /
PREGNANT
Weeks Gestation
Past Tx
Past Pregnancy
Site of Tx
Date of Tx
BLOOD URINE OTHERI certify that the pathology specimen accompanying the request was drawnfrom the patient stated above as established by direct inquiry and/or wrist bandand labelled immediately.
SIGNEDperson collecting sample specimen date & time
/ /
Urgent Phone
Fax
Pager No
Date
HRT
OCP
PLEASE USE DESIGNATED FORM FORBLOOD BANK REQUEST
LABUSE
x
Patient's signature DATE
EXPIRY DATE
/ /
/ /
SOUTHERN CROSS PATHOLOGY AUSTRALIASouthern Health APA 246 Clayton Road Clayton 3168
PATIENT DETAILS REQUESTING PRACTITIONER DETAILS
COPYTO:
TESTS REQUESTED: (for blood bank requests see reverse also)
SELF DETERMINE
REPORT DESTINATION
DOCTOR'SSIGNATURE X
or OP Clinic No:
UR
SURNAME
GIVEN NAMES
ADDRESS
SURNAME & INITIALS
ADDRESS
I offer to assign my right to benefits to the approved pathology practitioner who willrender the requested pathology service(s) and any eligible pathologist determinableservice(s) established as necessary by the practitioner.
Medicare number
Practitioner’s use only
(reason patient cannot sign)
Provider number
Date of Request
Patient status at time of service or when thespecimen was collected
(a) A private patient in a private hospital or approvedday hospital facility
(b) A private patient in a recognised hospital
(c) A public patient in a recognised hospital
(d) An outpatient of a recognised hospital
Yes No
SST LH FL ED CT ACD SY OT/ /
CYTOLOGY REQUESTS BLOOD BANK REQUESTS
SPECIMENTYPE:
INDICATIONS FORTEST:
SEX DOB / /
PREGNANT
Weeks Gestation
Past Tx
Past Pregnancy
Site of Tx
Date of Tx
BLOOD URINE OTHERI certify that the pathology specimen accompanying the request was drawnfrom the patient stated above as established by direct inquiry and/or wrist bandand labelled immediately.
SIGNEDperson collecting sample specimen date & time
/ /
Urgent Phone
Fax
Pager No
Date
HRT
OCP
PLEASE USE DESIGNATED FORM FORBLOOD BANK REQUEST
LABUSE
x
Patient's signature DATE
EXPIRY DATE
/ /
/ /
Pathology Request FormTelephone 03 9594 4538 Facsimile 03 9594 6619 A/4196
NATAAccredited for compliancewith AS 4633 (ISO 15189)
Pathology Request FormTelephone 03 9594 4538 Facsimile 03 9594 6619 A/4196
NATAAccredited for compliancewith AS 4633 (ISO 15189)
Expiry date...... /......
COPY TO Provider number: .......................................................................SURNAME & FIRST NAME: ...................................................ADDRESS: .....................................................................................................................................................................................
MonashPathologyMonashHealth (APA)
Result Enquiries 9594 4538
Clinical ConsultationAnatomical Pathology & CytologyAssoc. Prof. Beena Kumar
9594 3500BiochemistryAssoc. Prof. Zhong Lu
9594 4525
GeneticsDr Vivek Rathi 9594 5611
HaematologyAssoc. Prof. Sanjeev Chunilal
9594 4366
Infectious DiseasesAssoc. Prof. Tony Korman
9594 4564
MicrobiologyAssoc. Prof. Tony Korman
9594 4564
COLLECTION CENTRE ADDRESS TELEPHONE HOURS
CLAYTON Monash Medical CentrePublic Pathology collection rooms246 Clayton Road, Clayton
03 9594 2383 Monday to Friday08.30am - 5.00pm
Jessie McPherson Private Hospital Private Consulting Suites Suite G246 Clayton Road, Clayton
03 9594 2469 Monday to Friday8:00am – 6:00pmSaturday8:00am – 2:00pm
Monash Children’s Hospital246 Clayton Road, Clayton
03 8572 3072/3 Monday to Friday8.30am – 5.00pm
BERWICK Casey Hospital62 – 70 Kangan Drive, Berwick
03 8768 1442 Monday to Friday8.00am - 5.00pm
Berwick Healthcare76 Clyde Road, Berwick
03 9792 8021 Monday to Friday8.30 am - 5.00 pm
COWES Phillip Island Health Hub50-54 Church Street, Cowes
Monday to Friday 8.00am – 4.00pm Saturday 8.00am – 11.30am
CRANBOURNE Cranbourne Centre140 – 154 Sladen Street, Cranbourne
03 5990 6176 Monday to Friday8.30am – 5.00pmSaturday9.00am – 1.00pm
DANDENONG Dandenong Hospital135 David Street, Dandenong
03 9554 1901/2 Monday to Friday8.00am - 6.00pmSaturday & Sunday8.00am - 12 noon
Monash Health Community122 Thomas Street, Dandenong
03 9792 7854 Monday to Friday8.30 am - 5.00 pm
Monash Women’s Clinic135 David Street, Dandenong 03 9792 8003
Monday to Friday8.30 am - 5.00 pm
LANGWARRIN St. Augustine Family Medical CentreShop 18, 385 Cranbourne-Frankston Road, Langwarrin
03 8572 2122 Monday to Friday 8.30am –12.30pm
LEONGATHA Leongatha Hospital66 Koonwarra Road, Leongatha
Monday to Friday 8.00am – 4.00pm Saturday 9.00am – 11.00am
MOORABBIN Moorabbin Hospital823 – 865 Centre Road, East Bentleigh
03 9928 8178 Monday to Friday8.00am – 5.00pm
PAKENHAM Pakenham Health CentreHenty Way, Pakenham
03 5941 0526 Monday to Friday8.30am – 5.00pmSaturday8.00am – 12.00 noon
SPRINGVALE Greater Dandenong Community Health Service55 Buckingham Avenue, Springvale
03 8558 9012 Monday to Friday8.30am - 5.00pm
WONTHAGGI Wonthaggi Hospital235 Graham Street, Wonthaggi
Monday to Friday 8.30am - 5.00pmSaturday 8.30am – 10.30amSunday 8.00am – 12.00 noon
YARRAM Yarram Hospital85 Commercial Road, Yarram
Monday to Friday 8:00am - 2:30pm
MONASH PATHOLOGY REQUEST MINIMUM REQUIREMENTS1. Patient IdentificationRequest forms and specimens must be labelled with at least 3 patient identifiers:
i) Surname and first name in full with correct spellingii) Date of birthiii) At least one of the following - Monash Health UR number, Address, Gender
2. Date and time of Collection3. Specimen and request form must be signed by the specimen collectorREQUESTS WILL NOT BE ACCEPTED UNLESS ALL OF THE ABOVE ARE PRESENT.THIS INFORMATION IS NECESSARY FOR THE SAFETY OF THE PATIENT.
PLEASE NOTE:
l OPENING TIMES ARE SUBJECT TO CHANGE. CONTACT THE CENTRE OR GO TO monashpathology.org FOR UP TO DATE DETAILS.
l ALL COLLECTION CENTRES ARE CLOSED ON PUBLIC HOLIDAYS.
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 the provisions of the Health Insurance Act 1973. The information may be disclosed to the Department of Health or to a person in the medical practice associated with this claim, or as authorised/required by law.
Your treating practitioner has recommended that you use Monash Pathology. You are free to choose your own pathology provider.
However, if your treating practitioner has specified a particular pathologist on clinical grounds, a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your treating practitioner.
03 5671 3292
03 5182 0360
FOSTER TBA Monday to Friday 8.00am – 2.30pm
KORUMBURRA Monday to Friday 8.00am – 3.00pm
Foster Hospital87 Station Street, Foster
TBA
03 5667 5573
03 5951 2120
Korumburra Hospital65 Bridge Street, Korumburra
