Oral Request Form template
A form in the Pre-examination and Sample Handling procedure (PR20), mapped to ISO 15189:2022 clause 7.2. Fill it in whenever the task occurs. Used by the laboratory team.
FormISO 15189 · 7.2As needed
Calculated automaticallyRed = outside limits
Your LaboratoryOral Request Form | YL-LAB-FRM-20-F03 v1.0
Record: Oral Request Form — October 2026
Requesting Clinician NameR. Naidoo
Designation / WardMedical Technologist
Contact NumberREF-26-001
Date / Time of Request2026-10-01T08:30
Patient NameT. Moyo
Patient ID / Accession No.S26-1041
Additional Test(s) RequestedGlucose
Clinical Justification
Original Sample Available? (Y/N)Y
Appropriate for Additional Test? (Y/N)Y
New Accession No. (if new sample needed)S26-1041
READ-BACK CONFIRMATION:
Request read back to clinician? (Y/N)Y
Clinician confirmed accuracy? (Y/N)Y
Written request to be sent by (date)2026-10-01
Sign-off
| Role | Name | Signature | Date |
|---|---|---|---|
| Completed by | |||
| Reviewed by |
Shaded cells are calculated automatically. Values in red are outside their limits. † marks a corrected value (see Corrections).
Controlled document. Printed copies are uncontrolled unless stamped.Page 1
A4 portrait · first page · showing 0 of 0 rowsExactly as LabToolkit Pro prints it — with your logo and colours
What it records
- Requesting Clinician Name
- Designation / Ward
- Contact Number
- Date / Time of Request
- Patient Name
- Patient ID / Accession No.
- Additional Test(s) Requested
- Clinical Justification
- Original Sample Available? (Y/N)
- Appropriate for Additional Test? (Y/N)
- New Accession No. (if new sample needed)
- Request read back to clinician? (Y/N)
- Clinician confirmed accuracy? (Y/N)
- Written request to be sent by (date)
Instructions on the form
- READ-BACK CONFIRMATION:
Sign-off
- Completed by
- Reviewed by
Related templates
- Specimen Acceptance Criteria (reference Card) (PR20-F01)
- Sample Rejection Log (PR20-F02)
- Sample Acceptance Exceptions Log (PR20-F04)
- Sample Retention Schedule (PR20-F05)
- Sample Requirements, Transport Systems and Method Review Form (PR20-F06)
- Guide: ISO 15189 documentation checklist
Clause references are to ISO 15189:2022; check them against your licensed copy of the standard.