LABORATORY SERVICES REQUEST FORM
NOSOCOMIAL INFECTIONS LABORATORY
MULTIPLE ISOLATE REFERRAL REQUEST
PLEASE SPECIFY TESTS REQUIRED
REASON FOR INVESTIGATION
ORGANISM
Date received at ESR:
Date sent to ESR:
Name NHI No. Date of birth
Gender
Ward Site
Date
collected
Referring Lab No.
ESR USE ONLY
ESR Lab No. Result
NAME AND ADDRESS FOR REPORTING
Other:
Name:
Contact:
Phone:
Email:
ESR0804
vers 3.0 March 2020
DNA analysis using PFGE after restriction digestion
Staphylococcus aureus spa typing
Surveillance of (specify):
Other (specify):
Organism (specify):
Common source outbreak Sporadic infection Patient-to-patient spread
www.esr.cri.nz
INSTITUTE OF ENVIRONMENTAL SCIENCE AND RESEARCH LIMITED
Kenepuru Science Centre: 34 Kenepuru Drive, Kenepuru, Porirua 5022 | PO Box 50348, Porirua 5240, New Zealand
T: +64 4 914 0701 F: +64 4 914 0770
INSTRUCTIONS FOR USING FILLABLE FORMS: In Acrobat Reader, please complete this
form, then ‘SAVE AS PDF’ to your hard drive. Email to specimen.reception@esr.cri.nz
Print out your form and send to ESR with your specimen.
RESET FORM
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