Urinalysis Samples

Please complete this form when advised to do so. If you require treatment of further investigation you will be contacted within 1 working day.

If you are male and experiencing urinary symptoms please contact the Practice to arrange a telephone consultation.

Urinalysis Samples

Title *

Mrs/Miss/Ms/Other

First Name *

Last Name *

Email *

Enter Email

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Please answer the following questions

Could you be pregnant ? *

Yes

When was the 1st day of your last menstrual period?

Please use format day/month/year e.g. 12/04/2021

Have you got any vaginal discharge or itch? *

Yes

Duration of symptoms? *

Is this your first episode? *

Yes

Have you any pain passing urine? *

Yes

Are you passing urine more frequently? *

Yes

Do you have blood in your urine? *

Yes

Do you have a high temperature? *

Yes

Do you have pain in lower tummy or flank/side? *

Yes

Do you have a catheter? *

Yes

Are you allergic to any Antibiotics? *

Yes

Please provide the name (s) of any antibiotics you are allergic to *

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Your consent *

I consent to the practice collecting and storing my data from this form.

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