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Blood Test Request Form

Patients First name

Patients Last name

Patients Email

Patients phone number

Requesting Doctor (If applicable)

Doctors Email

Doctors Phone Number

Patients DOB

Month

Day

Year

Patients Age

Teudat Zehut or Passport

Pt Teudat Zehut/ Passport

Kupa?

Patients Address

Please make sure to include Street address, Knisa, Floor, Apt number

URGENT?

At Labriut or Home Visit?

Test Requested*

290 NIS Gen Chem 2: (Fast required, water is allowed) ALB TP GLOB A/G ALP GGT ALT AST TBIL UA UREA CRE AMY GLU CHOL TG HDL-C LDL-C

290 NIS Electrolyte & Renal Panel: K+ Na+ Cl- Ca Mg2+ P Co2 CRE UA UREA

290 NIS Clinical Emergency Panel: AST GLU AMY K+ Na+ Cl- Co2 CRE UA UREA CPK CK-MB LDH (lactic dehydrogenase) a-HBDH

130 NIS CBC

115 NIS Urinalysis

215 NIS CRP

400 NIS hsCRP

240 NIS Troponin - AMI cTnI

325 NIS D-Dimer

155 NIS B-HCG

160 NIS Ha1c

175 NIS TSH

355 NIS FT3

175 NIS FT4

600 NIS NT-proBNP

210 NIS Vitamin B12

310 NIS Vitamin D

245 NIS Testosterone

245 NIS Ferritin

350 NIS hGH Human Growth Hormone

155 NIS INR

All prices are NOT including VAT %18

Terms & Conditions

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