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Haematological Malignancy Diagnostic Service Request Form

Level 3, Leeds Cancer Centre, Bexley Wing, Beckett Street, Leeds, LS9 7TF
Tel: 0113 2067851       FAX: 0113 2067883
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Please telephone department if urgent result is required

Surname: [% data.last_name %] Forename(s): [% data.first_name %]
NHS number: [% data.nhs_number %] Patient/unit number: [% data.patient_number %]
DoB: [% data.dob %] Gender: [% data.gender %]
Location: [% data.location %] Consultant: [% data.referrer %]
Danger of infection: [% class = data.doi.match('YES') ? 'btn btn-danger btn-xs' : 'normal' %] [% data.doi %] Evidence of TB: [% class = data.tb.match('YES') ? 'btn btn-danger btn-xs' : 'normal' %] [% data.tb %]
Specimen type(s): [% data.specimen %]
Previously investigated: [% data.previous %]
Sample ref: [% data.sample_ref %]
Hb: [% data.hb %] Lymph: [% data.lymph %]
WBC: [% data.wbc %] Neut: [% data.neut %]
Plts: [% data.plt %] Other: [% data.other %]
Suspected diagnosis: [% data.diagnosis %]
Who should this report be returned to? [% data.report_to %]
Recent chemo/radiotherapy details: [% data.treatment %]
Clinical details: [% data.clinical_details %]
Specimen taken by: [% data.taken_by %] Contact details: [% data.contact %] Date/time: [% data.datetime %]