• YEHS - Pathology Request Form - Phoenix / Randox

  • PATIENT DETAILS

  • Date of Birth
     - -
  • Is patient above 50 years?*
  • Is male patient above 40 years?*

  • RANDOX - Assala Schedule C

    If using Randox for All > 50 years, add

    1. QFIT / FOB

  • RANDOX - Assala Schedule C

    If using Randox for Male > 40 years, request

    1. CHARLIE 17
    2. PR2
  • Tests

  • For CHARLIE 14 - Medilink Medical

    RANDOX Panel does not include Tetanus Antibody

    NWP and Phoenix Panel includes Tetanus Antibody

  • Tests
  • Australian Visa Medicals
  • Additional Tests 1
  • Additional Tests 2

  • You HAVE selected to do the HIV Test.
    Please print the HIV Pre Test document on pages 2, 3 and 4.
    You MUST give the patient to SIGN.

    PRINT PAGES 1, 2, 3, 4

  • You HAVE NOT selected to do the HIV Test.
    You DO NOT need to print the HIV Pre Test document on pages 2, 3 and 4.

    PRINT PAGE 1 ONLY

  • 0/60
  • 0/160
  • 0/120
  •  

  • If you would like patient data to be transferred to "Phoenix Imaging Request Form", then click "submit" and choose "View Info".

  • You HAVE NOT selected to do the HIV Test.
    You DO NOT need to print the HIV Pre Test document on pages 2, 3 and 4.

    PRINT PAGE 1 ONLY

  • You HAVE selected to do the HIV Test.
    Please print the HIV Pre Test document on pages 2, 3 and 4.
    You MUST give the patient to SIGN.

    PRINT PAGES 1, 2, 3, 4

    • Price Analysis - Randox vs Phoenix  
    • RANDOX - Sample Pick Up 

    • Sample can be collected by our couriers

      Book a pick up here

      ---------------

      Sample can be delivered directly to our Great Portland Street laboratory:

      Google Map to 143-149 Great Portland St, London W1W 6QN

      OPEN 24 Hours - If the clinic front is not open, Ring 0203 011 2973

    • Consent to disclosure of my Non-HIV health and HIV-related information
    • If you do consent, please check all that apply regarding what can be disclosed:
    • RANDOX - Randox Stock Order Form 

    • RANDOX - Randox Stock Order Form

       

      Customer Company Name:

      Your Excellent Health


      Customer Account Number:

      YEH001

       

      Contact Email Address: 

      yehs@yourexcellenthealth.org

       

      Customer Delivery Address:

      23 Harley Street, London, W1G 9QN

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