Infectious Disease Serology Request Form
Patient Information
Name
Date of Birth
Gender
Patient ID / MRN
Contact Number
Date of Collection
Requesting Physician
Name
Department
Serological Tests Requested
Test
Hepatitis B Surface Antigen (HBsAg)
Hepatitis B Surface Antibody (Anti-HBs)
Hepatitis C Antibody (Anti-HCV)
HIV 1/2 Antibody
Syphilis (TPHA/VDRL)
Dengue IgM/IgG
Rubella IgM/IgG
CMV IgM/IgG
Other
Remarks / Clinical Information
Requesting Physician Signature
Date