The Wellness Centre                    
   Westshore Medical Centre, Cocorite  
   Trinidad & Tobago  
   Tel: 622-9355  Fax: 622-3289  
   
     
  To:  
   
 
  Re:  
     
  Age:   Phone:  
     
  Ref: Dr.  
     
  Phone:  
     
  Please do the following tests on this client and charge to our account.    
  Results should be delivered/faxed to the address above    
 
Blood Pressure Fasting Blood Sugar
     
       
       
   
       
       
 
PSA Faecal Occult Blood Micro-urinalysis Complete Blood Count ESR HbA1c Liver Function Tests
  TSH Thyroid Profile HIV Blood group  
     
     
     
       
       
       
         
       
         
     
    Other:  
     
  done  
       
       
       
   

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