CENTRI - SAMPLE REFERRAL FORM
1. Referring Clinician/Health Care Practitioner Information:
Referring Clinician/Health Care Practitioner Name
Referring Hospital/Clinic/GP Practice/Medical Centre
Email
Contact Phone
Adress
2. Patient Information:
NHS Number
Patient Name
First Name
Last Name
Date of Birth
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Month
-
Day
Year
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Patient Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of patient / parent
3. Sample Details
Sample date:
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Month
-
Day
Year
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Sample type:
Sample species:
Sample origin type:
4. Reason for sample Referral:
Detailed Reason for Sample Referral:
5. Existing Resistance Test Results:
Microbiology (relevant samples and resistance results):
Virology (relevant samples and resistance results):
Other Diagnostic Tests:
Available Blood Tests:
6. Specific drugs to be tested:
What specific drugs would you like to be tested on this sample?
7. Consent and Declarations:
I confirm that I will send 1-2 mL of suspended sample in sterile water at 0.5 McFarland density with aproppiate sample transport biosafety
Referring Clinician's Signature:
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