Urgent Test Request
Submit a new Request
Patient Demographics
Forename:
Please enter the patient's forename
Surname:
Please enter the patient's surname
Date of Birth
Please enter a valid DOB
Hospital Number
Please enter a Hospital number
NHS Number
Please enter ten digit NHS number
Please enter hospital number and/or NHS number
Clinical Information
Is the patient stable or unstable?
Select an option
Stable
Unstable
Please enter if patient is stable or unstable
Is the patient bleeding or haemolysing?
Select an option
Bleeding
Haemolysing
Neither
Please specify if patient is bleeding or haemolysing
Patient's current Haemoglobin (g/l)
Select an option
20-29g/l
30-39g/l
40-49g/l
50-59g/l
60-69g/l
70-79g/l
80-100g/l
More than 100g/l
Please select HB range
Clinical Details:
Please provide clinical details
Has the patient been transfused in the last 3 months?
Select an option
Yes
No
Please enter date of last transfusion:
Please confirm whether the patient has been recently transfused
Please enter valid transfusion date
Hospital Information and Serological Results
Name of Hospital
Please select hospital name
Laboratory contact number:
Please enter a laboratory contact number
ABO group if known:
Select an option
O
A
B
AB
A2
A Variant
B Variant
AVarB
Bombay
Parabombay
Inconclusive
Please enter the patient's ABO group
RhD type if known:
Select an option
RhD Positive
RhD Negative
Weak D
RhD Variant
Please select a RhD group
Serological results obtained at hospital:
Please enter serological results obtained
Test Request
Please select test required:
Select a test
Antibody identification and phone call
Elution and phone call
Antibody identification and crossmatch
Please select test required
Additional Info
Date and time required:
Please Enter date and time required.
Please specify how the sample will be transported?
Please estimate date and time of arrival at referral lab:
Crossmatch Information
How many units are required?
Select an option
1
2
3
4
5
6
7
8
9
10
11
12
Please specify how many units are required
Special Requirements
Please specify the patients special requirements:
Irradiated
Washed
CMV Negative
HbS Negative
Less than 5 days old
Other
None
Please specify the patients special requirements
Unit Transportation
How should the units be transported?
Routine
AdHoc
Collect
Blue Light
Hospital services to arrange
Not stated