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Essex
About Us
Locations
Weymouth Street Hospital
9 Harley Street
25 Harley Street
Phoenix Hospital Chelmsford
One Ashford Hospital
One Hatfield Hospital
Services
View All Services
Blood Tests
General Practice (GP)
Paediatrics
Pharmacy
Diagnostics & Imaging
Cardiovascular Health
Cardiac MRI Scan
CT Colonography
CT Scan
DEXA Scan
Viability Scan (Early Pregnancy Scan)
Gynaecology
MRA Scan
MRI Scan
Paediatric Diagnostics
Pregnancy Scan London and Essex
Testicular Ultrasound Scan
Ultrasound Scan
X-Ray
Health Screenings
Executive Health
Health Screening
Bowel Cancer Screening
Complete Health Screening
Employee Health Screening
Executive Preventative Health Screening
Health Check Packages
Health Essential Package
Health Essential Plus Package
Prostate MRI Cancer Screening
Well Man Health Check
Well Woman Health Check
View All
Preventative Cancer Screening
Full Body MRI Cancer Screening in London
Prostate MRI Cancer Screening
Bowel Cancer Screening
Breast Cancer Screening
View All
Specialists
Patient Information
About
Blog
Careers
Feedback
Infection Control
International Patients
Management Team
Patient Experience
Patient Reported Outcome Measures
Paying for your care
Pre-assessment form
What our patients say
Healthcare Professionals
Contact Us
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Pathology Blood Form
Pathology Blood Form
This form is for medical professionals only.
Clinician Details
Clinician / Doctor Name*
Address
Telephone
Fax
Additional Copy of Results To
Patient Details
Title
Title
Mr
Mrs
Miss
Ms
Dr
Forename*
Surname*
M/F
M/F
Male
Female
Email*
Date of Birth*
Patient Ref / ID No.
Clinical Details
Clinical Details
Drug Therapy (if applicable)
Ethnic Origin (if relevant)
Fasting?
Yes
No
Profiles Requested
PP1 – Biochemistry
PP1L – Biochemistry/HDL
PP2 – Haem/Bio
PP2L – Haem/Bio/HDL
PP3 – Haematology
PP4 – Haem/Bio (short)
PP4L – Haem/Bio/HDL
PP5 – Postal Haem/Bio
PP5L – Postal Haem/Bio/HDL
PP6 – Well Person Screen
PP6L – Well Person Screen (HDL)
PP7 – Well Man Screen
PP7L – Well Man Screen (HDL)
PP8 – Well Woman Screen
PP8L – Well Woman Screen (HDL)
PP9M – Senior Male Profile 60+
PP9F – Senior Female Profile 60+
PP10 – Cardiovascular Risk Evaluation
PP11 – Cardiovascular Risk Plus
PP12 – Sexual Health 7 STI Screen
Do you require:
ECG
Home Visit
Additional Tests / Please Specify
Cervical Cytology & STI Tests
LMP Date
Last Smear (Month)
Last Smear (Year)
Smear Type:
Routine Screen
Colposcopy
Previous HPV:
Positive
Negative
Previous Abnormal History (if applicable)
Tests Required:
PAPT – Thin Prep Cervical Cytology
HPV – HR-HPV DNA
HP20 – 20 HPV DNA Subtypes
HPVT – Typed DNA/mRNA
TPCR – Thin Prep Chlamydia
TGON – Thin Prep Gonorrhoea
TCG – Thin Prep CT/GC
7 STI – PP12 Screen by PCR
Fee & Payment
Fee to be paid by:*
Doctor / Clinic
Patient / Other
Insurance Details
Patient Address
Postcode
Contact Telephone
Insurance Company
Membership No.
Doctor / Clinic Details
Signed (name)*
Date Sample Taken*
Time Sample Taken
Δ
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LONDON: 020 7079 2100
ESSEX: 01245 801234
