Pathology Request Form - Prime Cure Health

Doctor Details

Referring Doctor *

Practice Number *

Email *

Telephone *

Fax

Cell

Details of Principal Member

Surname *

First Name *

Email

Medical Scheme/ Insurance name *

Plan Option

Member Number *

Employer

Paypoint No

Patient Details

Surname *

First Name *

Postal Address *

Postal Address

City

Province

Postal Code

Email *

Dependant Code

Telephone

Fax

Cell

Identity Number / Passport *

Gender *

Male

Female

Age

Specimen Details

Start or Routine *

Start

Routine

Collection Time

Consultation Date

Pathology Practice Name

Practice Number

Clinical Information

Clinical Information *

ICD-10 Code *

Add Remove

Test Selection: The tests listed below do not require Pre-authorisation

Indicate by means of selection, Prime Cure Approved codes only (Please see Provider Manual for complete list of Codes)

Microbiology

Microscopy

Micro & Culture

Sputum TB AFB

Specimen

Cytology

PAP Smear (1 Slide)

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Application Date *

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