Gout Uric Acid Point of Care Test e-form

Gout Uric Acid Point of Care Test e-form

Maximum 2 funded tests per patient.
Patient Information
NHI
Date of Birth

DayMonthYear
Free type or use calendar date picker
Ethnicity
Town
Informed consent | Healthify
Patient Consent
URIC ACID TEST
Reason for Uric Acid Point of Care Test

Other
If test #1 was completed at the initial consultation - enter 2nd test into field #2.
Uric Acid PoC #1

Uric Acid Level (mmol/L)
Uric Acid PoC #2

Uric Acid Level (mmol/L)
Pharmacist Declaration
Pharmacy Name (choose from list)
Pharmacist Full Name

First NameLast Name
Pharmacy Dispensary Email
Pharmacist Declaration
Signature

Clear
Date of Uric Acid Test

DayMonthYear
Free type or use calendar date picker
Pharmacist: Please check all fields are accurate before submitting. A report will be emailed to your dispensary email.
Patient Full Name (REMOVE via PETE 15/12/2025)

First NameLast Name
Should be Empty:

URIC ACID TEST