THERAPEUTIC DRUG MONITORING (TDM) TEST REQUEST FORM CLINICAL CENTRE INFORMATION Lab21 ID DD1105 Requesting doctor Hospital/Clinic Homerton University Hospital QUERIES: Name Richard Castles Hospital/Clinic Address Department of Sexual Health 2026

1. Click ‘Get Form’ to open it in our editor.
2. Begin by filling out the 'Requesting doctor' section with your name, hospital/clinic name, and contact details including telephone and email.
3. In the 'PATIENT INFORMATION' section, affix the clinic label and provide necessary patient details such as Hospital/Clinic No., Weight, Height, Date of Birth, and Patient ID.
4. For the 'SAMPLE TO BE TESTED' section, specify the sample type, date taken, constituent drugs to be analyzed, and dosing information. Ensure to tick if ritonavir is included.
5. Indicate the reason for TDM by ticking applicable boxes in the 'REASON FOR TDM' section.
6. Add any additional comments in the provided space before finalizing your form.

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