Registration Form

 

I wish to enrol in the Antibiotic Assay Scheme and agree to abide by the conditions laid down in the current Participants Manual. Participant details such as name and address are held on file at CPHL, Colindale.

 

ANTIBIOTICS REQUIRED (PLEASE TICK ALL THAT APPLY)

 

Amikacin Teicoplanin Flucytosine

Tobramycin Gentamicin Vancomycin

 

ANTIFUNGAL PANEL

 

Itraconazole Flucytosine Posaconazole Voriconazole

Analyte requirements can be changed at any time by contacting the scheme.

Signed (Head of Department)......................................................

Name.......................................................................................

FULL LABORATORY ADDRESS

.............................................................

.............................................................

.............................................................

TELEPHONE NUMBER....................................................................

FAX NUMBER ...

CONTACT NAME..........................................................................

CONTACT E-MAIL

Please provide us with the following information:-

LAB TYPE

UK NHS laboratory UK HPA laboratory Private laboratory

University laboratory Other laboratory type

 

 

PLEASE RETURN THIS FORM TO: Scheme Manager, UK NEQAS for Antibiotic Assays, Dept. of Microbiology, Southmead Hospital, Bristol, BS10 5NB, UK.

Tel +44 (0)117 323 6214 OR Fax +44 (0)117 323 8332

 


SCHEME USE ONLY:

LAB REGISTERED ON DATABASE . (DATE)

UK NEQAS NOTIFIED . (DATE)

LAB NUMBER ASSIGNED .. (DATE)