Get Viral Load Request Form

Filling out the Viral Load Request Form online can streamline the process of submitting requests for viral load testing. This guide will provide clear, step-by-step instructions to ensure accurate completion of the form.

Follow the steps to accurately complete the Viral Load Request Form.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Enter the facility name in the designated field to identify where the sample is coming from.
3. Fill in the date and time the sample was dispatched to ensure proper tracking.
4. Input the facility MFL code, which is essential for identification and processing.
5. Provide the VL focal person’s name and contact information to ensure communication regarding the submission.
6. Enter the name and phone number of the requesting clinician to facilitate follow-up inquiries.
7. Specify the county and sub-county names relevant to the sample dispatch.
8. Input the facility email and phone number for any correspondence regarding the request.
9. Fill in the patient details including their name, date of birth, and complete CCC number as it appears in their records.
10. Select the sex of the patient; if the patient is female, indicate if they are pregnant or breastfeeding.
11. Select the sample type from the provided codes to indicate the kind of sample being submitted.
12. Record the date and time of sample collection and separation for accurate processing.
13. Indicate the date when the patient started on ART and specify the current ART regimen from the available codes.
14. Indicate whether the regimen is first-line or second-line therapy.
15. Select a justification code for the request as per the guidelines provided in the form.
16. If applicable, mark if the sample is to be rejected and provide the reason using the provided codes.
17. Once all fields are completed, review the form for accuracy, then save changes, download, print, or share the completed form as needed.

Start completing your Viral Load Request Form online today for efficient submission.