Cytology Requisition Form

A cytology requisition form is a formal document which is used in hospitals or other medical centres or institutes by doctors or nurses to write down the various details observed from tests conducted of the blood or urine samples of the patient. These forms help the doctors to understand the possible medical condition of the patient and to provide him/her with suitable medications or treatment. Any such form is an important document and is used by almost labs or hospitals to provide timely care to their patients. A sample of a cytology requisition form has been provided for you below for your reference purpose.

Sample Cytology Requisition Form:

Name of the Hospital/Medical Centre

Address of the Hospital/Medical Centre

CYTOLOGY REQUISITON FORM

Practitioner’s name:

Practitioner’s full address and phone number:

Sample provider name:

Date:                                  (dd/mm/yy)

Patient details:

Patient first name: ___________________             patient last name:________________

gender: __________________                                  Date of birth: _____________(dd/mm/yy)

cytology lab ID: ___________________

smear date: _________________(dd/mm/yy)            LMP date: ________________(dd/mm/yy)

HPV vaccination provided: ____________(yes/no)

Smear site(tick the one applicable)

• Cervix
• Endocervix
• Endometrial aspiration
• Lateral vaginal wall
• Labia
• Vulva
• Other(please specify)

Clinical information:

• Abnormal bleeding
• Suspicious lesion
• Using IUD
• Post menopausal
• Post partum
• Pregnant
• Other(please specify)

Uterine procedures:

• Colposcopy
• Bite biopsy
• Cone biopsy
• LEEP
• Laser
• Cryotherapy
• Pelvic radiation
• Other(please specify)

Clinical comments:

Laboratory use only:

Signature of lab incharge:_______________________

Signature of practitioner:______________________

Date of the Report: ______________________

Final results:

Category: Requisition Forms