All requests are subject to PHE standard terms and conditions. Version effective from Mar -2020 VW-2118.04
E28
PHE Microbiology request form
COVID-19 Primary Testing
IMPORTANT: please complete all elds below to avoid delays in processing.Please write clearly in dark ink
For samples for screening – please send to nearest designated testing laboratory see Guidance
Note: Testing for COVID-19 (SARS-CoV-2)- available from the designated testing laboratory
www.gov.uk/government/publications/wuhan-novel-coronavirus-guidance-for-clinical-diagnostic-
laboratories or bit.ly/2SafTX4
Report to be sent FAO
Contact Phone
In Hours
Out of Hours
Postcode
SENDER’S INFORMATION
Other (please specify)
Underlying Conditions including immunosuppression (please specify)
Asymptomatic URTI ILI Pneumonia
Onset Date
CLINICAL DETAILS
All samples submitted should be treated as though the
patient is infected with a Hazard Group 3 Pathogen.
All samples must be sent in accordance with Cat B
transport guidance.
Please tick the box if your clinical sample is post mortem
Your reference
Sample type
TS NS NS/TS BAL Sputum EDTA
Other
(please specify)
Date of collection Time
Date sent to PHE
SAMPLE INFORMATION
At Home Hospitalised ICU ECMO Deceased
CURRENT PATIENT STATUS
Other (please specify) Travel HCW Outbreak Clinical
Contact of conrmed case
Foreign travel within 14 days of onset? Yes No
If yes, travel to which country
Date of return
REASON FOR TESTING
Hospital number
Hospital name
(if different from sender’s name)
Ward/clinic name
InPatient OutPatient Community GP A&E
NHS number
Surname
Forename
Pregnant
Sex Male Female
Date of birth Age
Patient’s address
Postcode
PATIENT/SOURCE INFORMATION
dd mmm yyyy
dd mmm yyyy
dd mmm yyyy
dd mmm yyyy
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome