FOR LAB USE ONLY

LABORATORY REQUEST FORM

Mobile: (+63) 917-566-4137 www.singaporediagnostics.com

PATIENT DETAILS CLINIC STAMP

SURNAME FIRST NAME MIDDLE NAME

DATE OF BIRTH (MMM/DD/YYYY) GENDER AT BIRTH CONTACT NUMBER

M M M / D D / Y Y Y Y M / F

REPORT DELIVERY DOCTOR CLINICAL IMPRESSION

 Printed Copy  Deliver to MD/ Clinic ___________ NAME

MD
 Email ___________________________________

TEST REQUISITION

RPP
(RECOMMENDED PACKAGES
PATIENT PRICE)

3000 1500 1000 4000 6300 7200 8400 9300 15500 5500 7000
SINGLE TAG ON PARAMETERS ADDITIONAL TEST(S)
          
 300 CBC (14 Parameters) n n n n n n n n
 1000 RENAL PROFILE n n n n n n n
 240 Sodium n n n n n n n n
 240 Potassium n n n n n n n n
 240 Chloride n n n n n n n n
 200 Urea n n n n n n n n
 200 Creatinine w/ eGFR n n n n n n n n
 240 Calcium (Total) n n n n n n n
 240 Phosphorus n n n n n n n
 200 Uric Acid n n n n n n n n
 1000 LIVER PROFILE n n n n n n n
 240 Total Protein n n n n n n n
 240 Albumin n n n n n n n
 400 Globulin n n n n n n n
 400 A/G Ratio n n n n n n n
 200 ALT (SGPT) n n n n n n n n
 200 AST (SGOT) n n n n n n n n
 240 GGT n n n n n n n
 240 ALP n n n n n n n
 240 Total Bilirubin n n n n n n n
 600 FASTING LIPID PROFILE n n n n n n n n
 200 Total Cholesterol n n n n n n n n n
 200 Triglycerides n n n n n n n n
 300 HDL Cholesterol n n n n n n n n Refer to the back page for
 600 LDL & Non-HDL Cholesterol n n n n n n n n commonly requested tests
 600 VLDL Cholesterol n n n n n n n n
 400 Total Chol / HDL Ratio n n n n n n n n SPECIMEN DETAILS
 240 URINALYSIS (10 Parameters) n n n n n n n n
 900 DIABETIC SCREEN n n n n n n COLLECTED BY
 200 Glucose n n n n n n n n n
 800  350 HbA1c n n n n n n
 9000 HEART DISEASE SCREEN n
 500  250 hsCRP n n n n n n DATE (MMM/DD/YYYY) TIME (HH:MM)
 1600  800 Apolipoprotein A1 n n n
 1600  800 Apolipoprotein B n n n
 1600  800 Lipoprotein a - Lp(a) n n n
 2400  1200 Homocysteine n SPECIMEN TYPE
 2800  1400 hsTroponin n
 Fasting  Random
 2400  1200 BNP n
 2000 HEPATITIS SCREENING n  Others (Please Specify):
 1000  500 Hepatitis A IgG n
 400  150 Hepatitis B Surface Ab n n n n n n
 400  150 Hepatitis B Surface Ag n n n n n n
 1200  600 Hepatitis C Ab n SPECIMEN SUBMITTED
 1800 IRON STUDIES n
 240  120 Iron n n n n n n
 SST (Yellow)  Citrate (Blue)
 800  400 TIBC n  EDTA (Purple)  Urine
 800  400 Ferritin n
 Fluoride (Grey)  Stool
 1200  600 Transferrin n
 1500 THYROID FUNCTION TEST n  Pap Smear - LMP:_____________
 900  400 TSH n n n n n n  Swab - Site:__________________
 900  400 FT4 n n n
 900  400 FT3 n  Others (Please Specify):
 3200 BONE & JOINTS n
 600  300 Rheumatoid Factor n n n n n n
 2800  1800 Vitamin D n
 9000 CANCER MARKERS FOR LAB USE
 1800  650 AFP(Liver, Germ Cell) n n n n n n
 1800  650 CA 125 (Ovarian) n n n
 1800  650 CA 15-3 (Breast) n n n
 1800  650 CA 19-9 (Colorectal) n n n n n n
 1800  650 CEA (Colorectal, Thryoid) n n n n n n
 1800  650 Cyfra 21-1 (Lung Cancer) n n n n n n
 1800  650 HE4 (Ovarian) n n n
 1800  650 PSA - Total (Prostate) n n n
 1800  650 SCC Ag (Squamous Cell Carcinoma) n n n n n n
 ABOUT US

LOCATIONS SERVICE DETAILS

Corporate Office:
Singapore Diagnostics Singapore Diagnostics is among the largest
Singapore Medical Laboratories, Inc.
@singaporediagnostics laboratories in the Philippines. It services the laboratory
8F Sterling Centre requirements of up to 300 different institutions
131 Dela Rosa Street
Legaspi Village, Makati City 1229 nationwide, from the hospitals, to the largest clinic
Singapore Diagnostics chains, to free-standing physician clinics. It is also the
Philippines
only CAP Accredited tertiary laboratory in the
@sgdiagnostics Philippines – putting it alongside the world’s best
Laboratory:
laboratories.
+63 917 566 4137
Core Facility (Makati)
Dagupan City Satellite Laboratory
4F Sterling Centre +63 917 566 4137 When your laboratory tests are done at Singapore
ARB Corporate Center
131 Dela Rosa Street Diagnostics, be assured of the highest standards of
Tapuac District, Dagupan City 2400
Legaspi Village, Makati City 1229 [email protected] quality, competence and safety.
Davao Satellite Laboratory
Angeles City Satellite Laboratory
26 Sobrecarey St.
Alta Claro Building
Davao City 8000
McArthur Highway cor. San Pablo St.
Angeles City 2009
Iloilo Satellite Laboratory
GF Plazuela Dos
Cebu City Satellite Laboratory
Pison Avenue
Ayala Access Road
Mandurriao, Iloilo City 5000
Cebu City 6000
www.singaporediagnostics.com

TEST MENU

HEMATOLOGY THYROID ASSAYS HEPATITIS VALUE PACKAGES PARTNER LABORATORIES

ROUTINE HEMATOLOGY Anti Thyroglobulin 3600 HBV-DNA 7000 HEPATITIS PACKAGE
ABO & Rhesus Type 240 Thyroglobulin 4400 Hepatitis A IgG 1000 Hepatitis 1 (Hepatitis B Screening) 290 NON-INVASIVE PRENATAL TEST (NIPT)
Complete Blood Count 300 Anti TPO 3600 Hepatitis A IgM 1000 HBsAg, HBsAb Igene NIPT Core 25,000
CD4 5000 FT3 900 Hepatitis B Core IgM 1200 Hepatitis 2 (Hepatitis B Profile) 1280 Igene NIPT Comprehensive 35,000
ESR 240 FT4 900 Hepatitis B Core IgG (Total) 800 HBsAg, HBsAb, HBeAg, HBeAb
Malarial Smear 400 TSH 900 Hepatitis B Envelope Ab 800 HBc IgM, HBc Total
Peripheral Blood Smear 500 T3 900 Hepatitis B Envelope Ag 800 Hepatitis 3 (Hepatitis AB Profile) 1800
Reticulocyte Count 400 T4 900 Hepatitis B Surface Ab 400 HBsAg, HBsAb, HBeAg, HBeAb
COAGULATION T-Uptake 1800 Hepatitis B Surface Ag 400 HBc IgM, HBc Total
Bleeding Time 180 HORMONES Hepatitis C Ab 1200 HAV IgM, HAV IgG
Clotting Time 180 ACTH* 5300 SEROLOGY Hepatitis 4 (Hepatitis ABC Profile) 2200
PT (INR) 500 Anti- Mullerian Hormone* 6500 CMV (IgG) 4000 HBsAg, HBsAb COVID-19 TESTS
PTT (APTT) 500 Cortisol 1400 CMV (IgM) 5500 HBeAg, HBeAb
IMMUNOCHEMISTRY DHEAS 1400 Dengue Ab (IgG/IgM) 1800 HBc IgM, HBc Total RT-PCR Covid 19 Swab 5,000
ROUTINE CHEMISTRY Estradiol 900 Dengue NS1 Ag 3000 HAV IgM, HAV IgG, HCV Ab Covid-19 Antigen Swab 2,000
Albumin 240 FSH 900 Dengue Ab/Ag Combo 4200 ROUTINE CHEMISTRY Covid-19 Total Antibody 1,000
ALP 240 HCG (Qualitative) 400 H. pylori Ab (Qualitative) 2200 Electrolytes 400 Covid-19 IgG/ IgM 1,500
ALT (SGPT) 200 HCG (Quantitative) 900 H. pylori Ag (Stool) 1400 Na, K, Cl, CO2
Amylase 240 Insulin 2400 HIV Ag/Ab 800 Renal Function Test (RFT) 500
AST (SGOT) 200 Intact PTH 3000 RPR (Qualitative) 600 Na, K, Cl, Urea,Creatinine with eGFR
Bicarbonate (HC03) 240 Lutenizing Hormone (LH) 900 RPR (Quantitative) 1000 Liver Function Test (LFT) 600 ACCREDITED HMOs
Bilirubin - Direct 240 Progesterone 1200 Rubella IgG 1600 AST, ALT, ALP, GGT, LDH, Total Bilirubin
Bilirubin - Total 240 Prolactin 1400 Rubella IgM 1600 Lipid Profile, Non Fasting 400
Bilirubin Package (TB, DB, IB) 400 SHBG 3200 Rubeola IgG 4000 Cholesterol, HDL-C, Non-HDL-C
Calcium 240 Testosterone (Total) 1400 Syphilis Ab 600 Cholesterol/HDL Ratio
Chloride 240 Testosterone (Free & Total) 5000 Toxoplasma IgG 1000 Lipid Profile, Fasting 600
Creatine Kinase (CK) 240 SPECIAL CHEMISTRY Toxoplasma IgM 1000 Cholesterol, Triglycerides, HDL-C, Non-HDL-C,
CK- MB 800 Acid Phosphatase* 700 TPHA 1000 LDL-C, VLDL-C, Chol/HDL Ratio
CK- MM 1000 Anti CCP* 2800 Salmonella IgG/IgM (Typhidot) 900 SPECIAL CHEMISTRY PACKAGE
Creatinine (with eGFR) 200 Anti Streptolysin O 1200 CULTURE & SENSITIVITY CHEM 12 1800
GGT 240 ANA (IF)* 3000 Abscess Fluid C&S 1400 Na, K, Cl ,Total Protein, Albumin, Calcium
Glucose (Fasting) 200 ANA (Quantitative) 2700 Blood C&S 3000 Alkaline Phosphatase, Total Bilirubin
HbA1c 800 BNP 2400 Blood C&S with ARD 3500 BUN, SGOT, CO2, FBS
Ionized Calcium* 650 Complement 3 600 Body Fluid C&S 1400 CHEM 15 2200
Iron 240 C-Peptide 2700 Fungal Culture 1400 Na, K, Cl, Total Protein, Albumin, Calcium
Lactate Dehydrogenase (LDH) 240 Cystatin C 1800 Sputum C&S 1400 Alkaline Phosphatase, Total Bilirubin
Lipase 800 D-Dimer 5500 Stool C&S 1400 BUN, SGOT, CO2, FBS
Magnesium 240 Ferritin 800 Surveillance Culture 1400 Creatinine with eGFR, Uric Acid, Cholesterol
OGCT 600 Folate 1200 Swab C&S 1400 CHEM 16 2800
OGTT (3 Point) 1000 Homocysteine 2400 Urine C&S 1400 Na, K, Cl, Total Protein, Albumin, Calcium
Phosphorus 240 hsCRP 500 MICROSCOPY Alkaline Phosphatase, Total Bilirubin QUALITY ASSURANCE
Potassium 240 hsTroponin 2800 AFB Stain 400 BUN, SGOT, SGPT, FBS Singapore Diagnostics (SGD),
Sodium 240 IgA* 1400 Fecalysis 160 Creatinine with eGFR, Uric Acid, Cholesterol now among the world’s best
Total Protein 240 IgE 1600 Gram Stain 400 CHEM M 3600 laboratories.
TPAG 400 IgM* 1400 India Ink (Cryptococcus) 400 Na, K, Cl, Total Protein, Albumin, Calcium SGD is accredited by the College of
Urea 200 Procalcitonin 5700 iFOBT 800 Alkaline Phosphatase, Total Bilirubin American Pathologists (CAP), the
Uric Acid 200 Rheumatoid Factor 600 KOH Mount 400 BUN, SGOT, SGPT, FBS gold standard in laboratory quality.
LIPID STUDIES Serum Osmolality * 2400 Semen Analysis 400 Creatinine with eGFR, Uric Acid, Cholesterol
This makes SGD the first and only
Apolipoprotein A 1600 TIBC 800 Stool Conc. Technique 400 Triglycerides, HDL, LDL, Non-HDL ,Chol/HDL
tertiary laboratory in the Philippines
Apolipoprotein B 1600 Transferrin 1200 Urinalysis 240 CHEM 17 4300 to achieve this milestone, and one of
Cholesterol 200 Troponin T 7000 URINE DRUG TESTING Na, K, Cl, Total Protein, Albumin, Calcium less than 500 international
HDL Cholesterol 300 Vitamin B12 1600 Barbiturates 300 Alkaline Phosphatase, Total Bilirubin,LDH laboratories to meet the CAP
standards of accuracy, competence
LDL Cholesterol 600 Vitamin D 2800 Benzodiazepines 300 BUN, SGOT, SGPT, Triglycerides, Phosphorus
and safety.
Lipid Profile 600 URINE CHEMISTRY Cannabinoids 300 Uric Acid, Cholesterol, FBS ,CK
Lipoprotein a - Lp(a) 1600 Urine Albumin/ Creatinine Ratio 600 Cocaine 300 CHEM 19 4800 This proves that SGD is at par with
Non-Fasting Lipid Profile 400 Urine Amylase 600 Cotinine 300 Na, K, Cl, Total Protein, Albumin, Calcium,Triglycerides the best hospitals, medical centres
and reference laboratories in the
Non-HDL Cholesterol 400 Urine Calcium 400 Ecstasy 300 Alkaline Phosphatase, Total Bilirubin,Phosphorus
world.
Triglycerides 200 Urine Chloride 400 Meth/THC 300 BUN, SGOT, SGPT, Creatinine with eGFR
CANCER MARKERS Urine Creatinine 400 Opiates 300 Uric Acid, Cholesterol, LDH, CK, FBS
AFP 1800 Urine Creatinine Clearance 600 PCP 300 CHEM 23 5200
CA 125 1800 Urine Glucose 400 CYTOLOGY Na, K, Cl, Total Protein, Albumin, Calcium
CA 15-3 1800 Urine Magnesium 400 Pap Smear 800 Alkaline Phosphatase, Total Bilirubin, C02
CA 19-9 1800 Urine Micral Test 600 Fluid Cytology 2000 BUN, SGOT, SGPT, Creatinine with eGFR
CEA 1800 Urine Microalbumin 600 FNAB (per smear) 1000 Uric Acid, Cholesterol, LDH, Phosphorus
Cyfra 21-1 1800 Urine Osmolality 800 Urine Cytology 2000 CK , Amylase, FBS, GGTP, HDL, LDL,
HE4 1800 Urine Phosphorus 400 HISTOLOGY Non-HDL , Chol/HDL, Triglycerides
NSE call Lab Urine Potassium 400 0-5cm (small) 1400 COMPREHENSIVE METABOLIC PANEL 1800
PSA Profile 3600 Urine Pregnancy Test 400 5-7cm (medium) 2400 Creatinine (with eGFR), Na, K, Cl, C02 Price is subject to change without prior notice.
Tests marked with asterisk (*) are either batched
PSA - Free 1800 Urine Protein 400 7-15cm (large) 3200 BUN, Ca, Total Protein or referred out. For additional tests please call
PSA - Total 1800 Urine Sodium 400 >15cm (extra large) 4000 Total Bilirubin , Fasting Glucose our Core Lab.
SCC-Ag 1800 Urine Uric Acid 400 Gastric Bx - H.Pylori 1600 ALB, ALT, AST, ALP

NOVEMBER 2020 Singapore Diagnostics