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<td style="width: 60px; font-size: 28px;">⚕</td>
<td><strong style="font-size: 20px;">BALM OF GOD MEDICAL CENTER LTD.</strong><br><span style="font-size: 13px;">(Diagnostic Research Laboratory Service Division)</span><br><span style="font-size: 10px;">83 Nwaeke Street, off 104 Owerri Road, Aba | Tel: 0916 231 9889, 0705 200 1553</span></td>
<td style="background: #fff; color: #2c87b8; padding: 10px; text-align: center; font-size: 12px; width: 180px;"><strong>REQUEST/REPORTING FORM</strong></td>
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<div style="background: #f0f0f0; padding: 10px 20px; border-bottom: 1px solid #000; font-size: 10px;"><strong>DATE:</strong> <span style="border-bottom: 1px solid #666; display: inline-block; min-width: 100px;" contenteditable="true">________</span> &nbsp; <strong>PATIENT:</strong> <span style="border-bottom: 1px solid #666; display: inline-block; min-width: 200px;" contenteditable="true">______________</span> &nbsp; <strong>AGE:</strong> <span style="border-bottom: 1px solid #666; display: inline-block; min-width: 40px;" contenteditable="true">___</span> &nbsp; <strong>SEX:</strong> <span style="border-bottom: 1px solid #666; display: inline-block; min-width: 40px;" contenteditable="true">___</span><br><strong>DOCTOR:</strong> <span style="border-bottom: 1px solid #666; display: inline-block; min-width: 250px;" contenteditable="true">_________________</span> &nbsp; <strong>SPECIMEN:</strong> <span style="border-bottom: 1px solid #666; display: inline-block; min-width: 150px;" contenteditable="true">___________</span></div>
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<div style="background: #2c87b8; color: #fff; padding: 6px 10px; font-weight: bold; margin-bottom: 10px; font-size: 12px;">CHEMISTRY</div>
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<th style="border: 1px solid #666; padding: 5px;">TEST</th>
<th style="border: 1px solid #666; padding: 5px;">RESULT</th>
<th style="border: 1px solid #666; padding: 5px;">REFERENCE</th>
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<td style="border: 1px solid #666; padding: 5px;"><strong>FASTING BLOOD SUGAR</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style="border: 1px solid #666; padding: 5px;">75-115mg/dl</td>
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<td style="border: 1px solid #666; padding: 5px;"><strong>RANDOM</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style="border: 1px solid #666; padding: 5px;">75-135mg/dl</td>
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<div style="background: #2c87b8; color: #fff; padding: 6px 10px; font-weight: bold; margin-bottom: 10px; font-size: 12px;">LIVER FUNCTION TEST</div>
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<td style="border: 1px solid #666; padding: 5px;"><strong>TOTAL BILIRUBIN</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style="border: 1px solid #666; padding: 5px;">0.1-1.0mg/dl</td>
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<td style="border: 1px solid #666; padding: 5px;"><strong>DIRECT BILIRUBIN</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style="border: 1px solid #666; padding: 5px;">0.0-0.3</td>
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<td style="border: 1px solid #666; padding: 5px;"><strong>AST (SGOT)</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style="border: 1px solid #666; padding: 5px;">0-20IU/L</td>
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<td style="border: 1px solid #666; padding: 5px;"><strong>ALT (SGPT)</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style="border: 1px solid #666; padding: 5px;">0-20IU/L</td>
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<td style="border: 1px solid #666; padding: 5px;"><strong>ALK PHOSPHATASE</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style="border: 1px solid #666; padding: 5px;">40-125u/L</td>
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<td style="border: 1px solid #666; padding: 5px;"><strong>TOTAL PROTEIN</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style="border: 1px solid #666; padding: 5px;">60-82g/L</td>
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<td style="border: 1px solid #666; padding: 5px;"><strong>ALBUMIN</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style="border: 1px solid #666; padding: 5px;">30-50g/L</td>
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<td style="border: 1px solid #666; padding: 5px;"><strong>GLOBULIN</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style="border: 1px solid #666; padding: 5px;">10-35g/L</td>
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<td style="border: 1px solid #666; padding: 5px;"><strong>SODIUM</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style="border: 1px solid #666; padding: 5px;">135-150mmol/L</td>
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<td style="border: 1px solid #666; padding: 5px;"><strong>POTASSIUM</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style="border: 1px solid #666; padding: 5px;">3.5-5.5mmol/L</td>
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<td style="border: 1px solid #666; padding: 5px;"><strong>CHLORIDE</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style="border: 1px solid #666; padding: 5px;">95-110mmol/L</td>
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<td style="border: 1px solid #666; padding: 5px;"><strong>BICARBONATE</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style="border: 1px solid #666; padding: 5px;">21-31mmol/L</td>
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<td style="border: 1px solid #666; padding: 5px;"><strong>CALCIUM</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style="border: 1px solid #666; padding: 5px;">8.5-11mg/dl</td>
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<td style="border: 1px solid #666; padding: 5px;"><strong>MAGNESIUM</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style="border: 1px solid #666; padding: 5px;">1.7-2.1(MG/d)</td>
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<td style="border: 1px solid #666; padding: 5px;"><strong>PHOSPHORUS</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style="border: 1px solid #666; padding: 5px;">2.5-4.5mg/dl</td>
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<td style="border: 1px solid #666; padding: 5px;"><strong>URIC ACID</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style="border: 1px solid #666; padding: 5px;">3.4-7.0mg/dl<br>2.5-6.5u, mg/dl</td>
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<td style="border: 1px solid #666; padding: 5px;"><strong>CREATININE</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style="border: 1px solid #666; padding: 5px;">0.6-2.0mg/dl</td>
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<td style="border: 1px solid #666; padding: 5px;"><strong>UREA</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style="border: 1px solid #666; padding: 5px;">10-50mg/dl</td>
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<div style="background: #2c87b8; color: #fff; padding: 6px 10px; font-weight: bold; margin-bottom: 10px; font-size: 12px;">LIPID PROFILE</div>
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<td style="border: 1px solid #666; padding: 5px;"><strong>CHOLESTEROL</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style="border: 1px solid #666; padding: 5px;">120-230mg/dl</td>
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<td style="border: 1px solid #666; padding: 5px;"><strong>TRIGLYCERIDES</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style="border: 1px solid #666; padding: 5px;">&lt;140mg/dl</td>
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<td style="border: 1px solid #666; padding: 5px;"><strong>HDL</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style="border: 1px solid #666; padding: 5px;">&gt;60mg/dl</td>
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<td style="border: 1px solid #666; padding: 5px;"><strong>LDL</strong></td>
<td style="border: 1px solid #666; padding: 5px; text-align: center;"><span contenteditable="true">___</span></td>
<td style