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Form of Identity - HDFC

This document provides a form for collecting medical report information. It requests the examinee's name, gender, date of birth, height, weight, and method of identification. Any visible identification marks should be noted. The form lists various medical tests that may be conducted, including urine analysis, blood tests, imaging, and cardiac tests. The medical examiner and examinee must sign and date the form, and the examiner provides their code number and stamp. Photographs of the examinee are also requested to be submitted with the completed medical reports.

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142 views

Form of Identity - HDFC

This document provides a form for collecting medical report information. It requests the examinee's name, gender, date of birth, height, weight, and method of identification. Any visible identification marks should be noted. The form lists various medical tests that may be conducted, including urine analysis, blood tests, imaging, and cardiac tests. The medical examiner and examinee must sign and date the form, and the examiner provides their code number and stamp. Photographs of the examinee are also requested to be submitted with the completed medical reports.

Uploaded by

seenasrinivas113
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Form of Identity for Medical Reports

Application Number:

Place of examination: Medical Centre Residence

Examinee Name: S U R N A M E F I R S T N A M E M I D D L E N A M E

Gender: M F Date of Birth: D D M M Y Y Y Y Height: cm Weight: kg

Identified by: Passport Election Id Pan card Driving License Aadhar Card Any other ID____________________

Any visible identification Marks:

Serial Number of ID Card:

Medical test to be conducted: Please tick  on the relevant tests as mentioned on the medical requisition letter issued to you.

Midstream Urine Analysis HbsAg - Australia Antigen Test CTMT- Computerised Treadmill Test

Urine Cotinine Test S.Uric Acid 2D Echo-cardiography-Doppler study

Complete Haemogram S. Creatinine USG Abdomen and pelvis

Fasting Blood Sugar Serum Cholesterol Others 1) _______________________

HbA1c - Glycosulated Heamoglobin Serum Lipid Profile Others 2)_______________________

PG2 - Post Glucose tolerance Test HIV I & II Others 3) _______________________

Biochemistry Chest X Ray Others 4)_______________________

LFT - Liver Function Test ECG - Electrocardiogram Others 5) _______________________

SIGN HERE SIGN HERE

STAMP HERE

Signature of Medical Examiner Stamp of Medical Examiner Signature /Thumb impression of Examinee
(In presence of medical examiner)

Date: D D M M Y Y Y Y Code Number:

Place:

Tpa Name: Location:

Name of Diagnostic Centre/Clinic:

Instruction to the Examining Doctor/Pathologist - Please establish the identification of the client before you conduct the medical tests.
Request you to capture the Photograph of the client and submit the same along with the complete medical reports.

Complete Haemogram - WBC, RBC, Heamoglobin, Hematocrit, Platelets MCV, MCH, MCHC,DC Count
LFT - Total Protein, Albumin, Creatinine, Bilirubin (Total, Direct & Indirect), SGOT, SGPT & Gamma GT
Lipid Profile -Total Cholesterol + HDL + LDL + Triglycerides +VLDL
Biochemistry - Total Protein, Albumin, Creatinine, Bilirubin (Total, Direct & Indirect), SGOT, SGPT, Gamma GT
PG2 - FBS , Post Glucose Value (2 hrs Post Glucose Test where 75 gm of glucose need to be provided by DC to the client.

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