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Haematological Malignancy Diagnostic Service Request Form
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<strong>Level 3, Leeds Cancer Centre, Bexley Wing, Beckett Street,
Leeds, LS9 7TF<br />Tel: 0113 2067851
FAX: 0113 2067883</strong>
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<td>[% data.barcode %]</td>
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Please telephone department if urgent result is required
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<td><span class="fieldname">Surname:</span>
<span class="text-uppercase">[% data.last_name %]</span>
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<td><span class="fieldname">Forename(s):</span>
<span class="text-capitalize">[% data.first_name %]</span>
<span class="text-capitalize">[% data.middle_name %]</span>
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<td><span class="fieldname">NHS number:</span>
<span class="text-uppercase">[% data.nhs_number %]</span>
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<td><span class="fieldname">Patient/unit number:</span>
<span class="">[% data.patient_number %]</span>
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<td><span class="fieldname">DoB:</span>
<span class="">[% data.dob.dmy %]</span>
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<td><span class="fieldname">Gender:</span>
<span class="text-capitalize">[% data.gender %]</span>
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<td><span class="fieldname">Location:</span>
<span class="text-capitalize">[% data.location_name %]</span>
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<td><span class="fieldname">Consultant:</span>
<span class="text-capitalize">[% data.referrer %]</span>
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<span class="fieldname">Danger of infection:</span>
[% class = data.doi.match('YES')
? 'btn btn-danger btn-xs' : 'normal' %]
<span class="[% class %]">[% data.doi %]</span>
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<span class="fieldname">Evidence of TB:</span>
[% class = data.tb.match('YES')
? 'btn btn-danger btn-xs' : 'normal' %]
<span class="[% class %]">[% data.tb %]</span>
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<span class="fieldname">Previously investigated:</span>
[% data.previous %]
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<span class="fieldname">Specimen type(s):</span>
[% data.specimen %]
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<span class="fieldname">Sample ref:</span>
[% data.sample_ref %]
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<td><span class="fieldname">Hb:</span> [% data.hb %]</td>
<td><span class="fieldname">Lymph:</span> [% data.lymph %]</td>
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<td><span class="fieldname">WBC:</span> [% data.wbc %]</td>
<td><span class="fieldname">Neut:</span> [% data.neut %]</td>
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<td><span class="fieldname">Plts:</span> [% data.plt %]</td>
<td><span class="fieldname">Other:</span> [% data.other %]</td>
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<span class="fieldname">Suspected diagnosis:</span>
[% data.diagnosis %]
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<span class="fieldname">Who should this report be
returned to?</span>
[% data.report_to %]
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<span class="fieldname">Recent chemo/radiotherapy
details:</span> [% data.treatment %]
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<span class="fieldname">Clinical details:</span>
[% data.clinical_details %]
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<span class="fieldname">Specimen taken by:</span>
[% data.taken_by %]
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<span class="fieldname">Date/time:</span>
[% data.datetime %]
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<span class="fieldname">Contact details:</span>
[% data.contact %]
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<div class="text-danger bg-danger" align="center">
PLEASE ATTACH DOI STICKERS FOR HIGH-RISK SAMPLES
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<div class="strong" align="center">For Laboratory Use Only</div>
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<td width="50%">Date & time:</td>
<td width="25%">Initials:</td>
<td width="25%">HMDS Error Code:</td>
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<u>Gross description / contents:</u>
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........ core of tissue ....... mm in length
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