Albador ATM Laboratory Analyses Order

Albador ATM Advanced Technologies Medicine
Laboratory Analyses Order

This form is going to be send to the laboratory to get particular biochemical characteristics of our patient.

Please fill in the fields below properly by choosing the selection that would bring better understanding about health condition of our patient.

PERSONAL DATA MANAGEMENT STATEMENT
The information that is provided will remain strictly confidential.
It will be used exclusively by Albador ATM experts to establish the patient’s health condition.

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1/2. PATIENT'S PERSONAL DATA

Name

First

Middle

Last

2/2 (0 Weight

Gender

Birthday Day/Month/Year

Country

City

Postal Code

Postal Address 1

Postal Address 2 (optional)

House Number

Email Address

Phone Type

Country Phone Code

Phone Number

Insurance Company

Insurance Number

Height / cm

Weight / kg

2/2. LIST OF THE LABORATORY TESTS

2/20. COAGULATION TESTS

P – PČ, INR 2,50
P – PTČ 2,50
P – D-DIMER 18,00

3/20. HEMATOLOGICAL TESTS

K – HEMOGRAM 2,70
K – DKS MANUAL 1,50
K – RETICULOCYTES 1,50
K – SEDIMENTATION 1,50

4/20. URINE TESTS

U – – BASIC ANALYSIS 2,00
U – SEDIMENT 2,00
U – URICULT 2,00

5/20. STOOL

F – PRESENCE OF BLOOD 4,17
F – HELICOBACTER PYLORI 9,00

7/20. OTHER TESTS

INFECTIOUS MONONUCLEOSIS 10,00
BLOOD COLLECTION 2,00

List of medications the patient is taking

Other information about the patient that may be relevant prior to testing

Satisfaction Rating of this Analyses Order (0 = low, 10 = high)

Selected Value: 0

Consent to Medical purposes

By submitting this Albador ATM Analyses Order, I agree to the use of personal information for medical purposes.

Albador ATM Laboratory Analyses Order

Albador ATM Advanced Technologies MedicineLaboratory Analyses Order

Albador ATM Partners

Albador ATM Advanced Technologies Medicine
Laboratory Analyses Order