Urinary tract infection (UTI)

Sex: *

Male

Female

Indeterminate

If dropping a urine sample off, please use an appropriate sterile container and complete the following:

Women Only

Are you Pregnant? *

Yes

No

Possibly Pregnant

What was the date of last period? *

Please use this date format: DD/MM/YYYY

Urine Specimen

Date of Sample: *

Please use this format dd/mm/yyyy.

Requested by: *

GP

Nurse

Health Care Assistant

Other

Please specify who requested this specimen: *

Reason: *

Suspected urinary tract infection (UTI)

Follow-up after treatment (This must be requested by a Doctor or Nurse to check blood has gone from urine after infection)

Early morning sample to check for protein (ACR, commonly requested for diabetics or patients with kidney problems)

To check for specific protein (Bence Jones Protein)

Other

Please specify the reason for this urine specimen: *

Symptoms

How long have you had these symtoms?

Please specify in days.

Treatments

Please specify any treatments you have tried:

Allergies

Do you have any allergies? *

Yes

No

Please specify what you are allergic to: *

Catheter

Please select an option: *

I have a permanent urinary catheter

I have a temporary urinary catheter

I intermittently self-catheterise

I do not have a catheter / I do not have to self-catheterise

Consent

I consent to receiving my results by text message if I am unobtainable by phone: *

Yes

No

What happens now?

Your sample will be tested if appropriate and the results passed to one of our clinicians. If your sample is positive for a urine infection, you may be issued with an antibiotic prescription if needed. You will be telephoned and informed about this by reception. It is possible that your sample will need to be sent to the laboratory for further analysis. It can take five days before the result is back from the laboratory. If your symptoms continue despite antibiotics, please contact the surgery and reception will advise you on the next steps.

Please note if your sample tests negative for infection and there are no documented symptoms of infection you will not be called. If you go onto develop symptoms or become unwell, please contact the surgery.

Tell us whether you accept cookies