Get Request Form For Genexpert Accelerating Access To Tb - Nirt Res

This guide provides clear and supportive instructions on completing the Request Form for GeneXpert Accelerating Access to TB Diagnosis for Presumptive Pediatric Cases. Follow the steps outlined to ensure accurate and efficient submission of your request.

Follow the steps to complete the online request form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the 'Patient Details' section. Provide the full name, residential address, mobile number, age, and sex of the patient.
3. Next, complete the 'Referring Health Facility Details.' Enter the name of the facility, physician's name, address, mobile number, and email address.
4. In the 'Specimen Collection Details' section, specify the date and time of specimen collection. Indicate the type of specimen collected by ticking the appropriate options, and specify the nature of the specimen.
5. Fill in the 'History' section, providing details on the provisional diagnosis, previous history of anti-tuberculosis treatment (ATT), and contact history with options for any previous TB or multidrug-resistant TB (MDR-TB) cases.
6. For the 'Results' section, leave the fields blank as they are designated for official NIRT use. This includes the specimen receipt date, smear result, lab number, dispatch date, XPERT result, and any remarks that may be added later.
7. Lastly, ensure that the 'Acknowledgement Copy for Specimen Receipt' section is left empty for the NIRT staff to fill in details like receipt date, referral hospital, lab number, name, and patient age/sex.
8. After reviewing the completed form for accuracy, proceed to save your changes, download, print, or share the form as necessary.

Complete your Request Form for GeneXpert online to facilitate timely access to TB diagnosis.