Procedure form · Renal biopsy

Renal biopsy specimen referral form

For native kidneys only

All renal biopsy forms

Home › Procedure forms › Renal biopsy specimen referral form

Fill in on screen and print, or print it blank. This form goes to the pathology laboratory with the sample bottles.

For native kidneys only. All fields are mandatory. Write ND for anything not done.

Fill in, then print

Type the details and tick the boxes here, then press Print. Or print the blank form and fill it in with a pen. Nothing typed here is sent or saved.

Patient name Date Date of birth Age

Sex

MaleFemaleOther

Height (cm) Weight (kg) Phone no. Address

Samples sent

Tick each sample sent

Biopsy for LM (in Bouin's or formalin)Biopsy for IF (in saline or Zeus)Biopsy for EM (in glutaraldehyde)

1. Biopsy date and time

2. Previous biopsy

YesNo

If yes, date and number of the previous biopsy

3. Clinical diagnosis or presentation

Clinical diagnosis or presentation

5. Medical history, with duration

6. Treatment

If yes, write the drugs and the doses.

7. Laboratory data

Creatinine (mg/dl)Creatinine clearance (ml/min)Serum albuminProteinuria (g/24 h)Urine cultureUrine sediment: RBCUrine sediment: WBCUrine sediment: casts

USG findings

Right kidney (RK)Left kidney (LK)

Referred by

Referring nephrologistHospitalPhone no.

Nothing filled in yet. The form will print with blank lines.