Patient details
Hospital number
* Required
NHS number
* Required
Surname
* Required
First name
* Required
Gender
* Required
Date of birth
* Required
Date
Sample details
Date and time of sample
* Required
Date Time (Hours) 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 : Time (Minutes) 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59
Specimen type
* Required
Referral lab number
* Required
Number of samples
* Required
Requesting consultant
* Required
Clinical details:
* Required
Requesting hospital details
Reports address (must include department)
* Required
Telephone number
* Required
Billing address (if different to reports address)
Test requests
Tests available.
Neurology Biomarkers
Neurodegenerative screen
Neuroimmunology autoimmune antibodies
CSF biochemistry analysis
Other tests (please specify)
