{"id":6861,"date":"2026-05-03T02:18:18","date_gmt":"2026-05-03T00:18:18","guid":{"rendered":"https:\/\/www.gammalab.sk\/?page_id=6861"},"modified":"2026-05-14T11:20:59","modified_gmt":"2026-05-14T09:20:59","slug":"request-form","status":"publish","type":"page","link":"https:\/\/www.gammalab.sk\/en\/request-form\/","title":{"rendered":"Request Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"6861\" class=\"elementor elementor-6861 elementor-6860\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-407f721 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"407f721\" data-element_type=\"section\" data-e-type=\"section\" id=\"hore\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-dd12e3d\" data-id=\"dd12e3d\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-70acc73 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"70acc73\" data-element_type=\"section\" data-e-type=\"section\" id=\"hore\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-40a66a07\" data-id=\"40a66a07\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section data-dce-background-color=\"#8FE0DB2B\" data-dce-background-overlay-image-url=\"https:\/\/www.gammalab.sk\/wp-content\/uploads\/sites\/14\/2026\/05\/BG-Service-one-inverz3.png\" class=\"elementor-section elementor-top-section elementor-element elementor-element-d8c027d elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"d8c027d\" data-element_type=\"section\" data-e-type=\"section\" id=\"druhy-vysetreni\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-349d414a\" data-id=\"349d414a\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-9ea674 elementor-widget elementor-widget-text-editor\" data-id=\"9ea674\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Request Form<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div data-dce-title-color=\"#00A19A\" class=\"elementor-element elementor-element-453e7011 elementor-widget elementor-widget-heading\" data-id=\"453e7011\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Scintigraphy Examination Request Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-40470f01 elementor-button-align-stretch elementor-widget elementor-widget-form\" data-id=\"40470f01\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;\\u010eal\\u0161ie&quot;,&quot;step_previous_label&quot;:&quot;Predo\\u0161l\\u00e9&quot;,&quot;dce_enable_tooltip&quot;:&quot;yes&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;,&quot;label_icon_size&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;field_icon_size&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;dce_tooltip_placement&quot;:&quot;top&quot;,&quot;dce_tooltip_arrow&quot;:&quot;yes&quot;,&quot;dce_tooltip_follow_cursor&quot;:&quot;false&quot;,&quot;dce_tooltip_max_width&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:200,&quot;sizes&quot;:[]},&quot;dce_tooltip_max_width_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;dce_tooltip_max_width_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;dce_tooltip_touch&quot;:&quot;true&quot;,&quot;dce_tooltip_zindex&quot;:&quot;9999&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"\u017diadanka na vy\u0161etrenie GAMMALAB\" aria-label=\"\u017diadanka na vy\u0161etrenie GAMMALAB\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"6861\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"40470f01\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"GAMMALAB - Pre Lek\u00e1rov - Oddelenie nukle\u00e1rnej medic\u00edny\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"6861\"\/>\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_60963c7 elementor-col-100\">\n\t\t\t\t\t<h4 style=\"text-align:center; margin-top:40px; margin-bottom:20px;\">\n   Patient Details\n<\/h4>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-menopac elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-menopac\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPatient\u2019s Full Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[menopac]\" id=\"form-field-menopac\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-rc elementor-col-25 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-rc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNational ID\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[rc]\" id=\"form-field-rc\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-poistovna elementor-col-25 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-poistovna\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHealth Insurance\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[poistovna]\" id=\"form-field-poistovna\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-telpac elementor-col-30 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-telpac\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPatient\u2019s Phone Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[telpac]\" id=\"form-field-telpac\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-bydliskopac elementor-col-30 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-bydliskopac\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPatient\u2019s Address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[bydliskopac]\" id=\"form-field-bydliskopac\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-hmotnost elementor-col-20 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hmotnost\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWeight\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[hmotnost]\" id=\"form-field-hmotnost\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"v kg\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-vyska elementor-col-20 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-vyska\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHeight\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[vyska]\" id=\"form-field-vyska\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"v cm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-alergia elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-alergia\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAllergy History\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[alergia]\" id=\"form-field-alergia\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_371df4a elementor-col-100\">\n\t\t\t\t\t<h4 style=\"text-align:center; margin-top:40px; margin-bottom:20px;\">\n   Referring Physician\n<\/h4>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-menolek elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-menolek\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhysician\u2019s Full Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[menolek]\" id=\"form-field-menolek\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-den elementor-col-25 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-den\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhysician Code\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[den]\" id=\"form-field-den\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_00201d8 elementor-col-25 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_00201d8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDepartment Code\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_00201d8]\" id=\"form-field-field_00201d8\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_ce5bcb0 elementor-col-100\">\n\t\t\t\t\t<h4 style=\"text-align:center; margin-top:40px; margin-bottom:20px;\">\n   Specification\n<\/h4>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-diagnoza elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-diagnoza\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDiagnosis\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[diagnoza]\" id=\"form-field-diagnoza\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-organ elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-organ\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOrgan to Be Examined:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[organ]\" id=\"form-field-organ\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-otazka elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-otazka\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tClinical Question:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[otazka]\" id=\"form-field-otazka\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-vysetrenia elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-vysetrenia\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPrevious Examinations Performed (Laboratory Tests, Other Imaging Techniques):\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[vysetrenia]\" id=\"form-field-vysetrenia\" rows=\"4\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-epikriza elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-epikriza\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBrief Medical Summary:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[epikriza]\" id=\"form-field-epikriza\" rows=\"4\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_0177269 elementor-col-100\">\n\t\t\t\t\tPlease print and sign the completed request form in two copies. The original must be brought by the patient to the examination.\n\nThe examination request form must be issued by the referring physician who is authorized to indicate radiological examinations. Patients without a properly signed and stamped request form cannot undergo the examination.\n\nBy submitting the request, the physician confirms that the patient has been examined, that the requested examination is considered appropriate, and that it is expected to contribute to the patient\u2019s further diagnosis and treatment.\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"far fa-arrow-alt-circle-right\"><\/i>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">SEND AND PRINT<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Request Form Scintigraphy Examination Request Form<\/p>\n","protected":false},"author":6,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-6861","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.2 - 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