Templates

DIAG-01

DIAG-01ISO 15189

Laboratory Test Request សំណើធ្វើតេស្តមន្ទីរពិសោធន៍

Diagnostic & Laboratory ការធ្វើរោគវិនិច្ឆ័យ និង មន្ទីរពិសោធន៍

BS DERMA

Clinic Management System

REQUEST DATE

MRN

PRIORITY

PATIENT TYPE / ប្រភេទ

REQUESTING PHYSICIAN

Full Name*

DOB*

Sex*

Contact Number / ទូរស័ព្ទ

Age / អាយុ

Ward/Clinic / ផ្នែក

Bed # / លេខគ្រែ

Diagnosis / Clinical Indication / រោគវិនិច្ឆ័យ

Relevant History / ប្រវត្តិទាក់ទង

Special Instructions / ការណែនាំពិសេស

URGENT / STAT REQUEST — Notify physician immediately upon critical results

⚠️CRITICAL ALERT: Label specimens immediately at bedside. Never label pre-collection. Verify patient identity with two identifiers.

Specimen Type	Collection Date	Collection Time	Collector	Barcode #

Requesting Physician

វេជ្ជបណ្ឌិតស្នើ

Signature

Specimen Collector

អ្នកប្រមូលសំណាក

Signature

Lab Received By

មន្ទីរពិសោធន៍ទទួល

Signature

BS Derma Clinic | Lab Request Form | Template: DIAG-01 v2.0