Urinalysis Samples

Only complete this form if you have been asked to.

If you need treatment or further investigation we will contact you within 1 working day.

If you are male and have urinary symptoms contact us to arrange a consultation.

Your Details

Title

First Names

Surname

Date of BirthDD/MM/YYYY

Home Address

Postcode

Best telephone number to contact you

One of the clinicians will call you on the number provided in the next couple of weeks

Females Only

Are you / Could you be pregnant?

When was the 1st day of your last menstrual period

Do you have a vaginal discharge or irritation currently?

If yes, please provide more information including how long you have had this

For all patients

Is this the first time you have experienced this problem?

Do you have any pain when passing urine?

Are you passing urine more frequently?

Do you have blood in your urine?

Do you have a high temperature?

Do you have pain in your lower tummy (abdomen)

Do you have pain in flank/side?

Do you have a catheter?

Are you allergic to any antibiotics?

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Ongar Health Centre • Ongar War Memorial Medical, Fyfield Road, Ongar, Essex, CM5 0AL.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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