Application Form for Requestors
Doctor, Clinician, Midwife, Smeartaker
Locum * ^^
Smear taker **
* Specialist / GP / Locum? - NZMC # please
** Midwife / Smeartaker? - ID please
^^ Locum? Duration of time at that practice?
AFTER HOURS #
DHB (District Health Board) REGION
Pathlab collects this information to facilitate the sending of laboratory results and related health information. Pathlab will also share this information with other organisations within the health sector for clinical purposes.
I hereby authorise Pathlab to use the information herein as they require in the receipt and delivery of test results.
I confirm that all information contained in this form is correct.
Address Line 2
City / Postal Code