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The image shows a Haematology Request/Report form from Gombe State Hospital Services Management Board, Specialist Hospital, Gombe, Nigeria. The form is filled out by hand in black ink. The patient's surname is "Buba" and other name is "Magaji". The form is dated 06/15/2023. The patient's sex is not specified. The form contains sections for clinical details, investigation(s) required, clotting profile, and prothrombin time, and also includes sections for grouping and crossmatching, and comments. The form is filled out partially, showing the patient's blood group, and investigation results for a blood test. The environment appears to be a hospital or clinic. The image was taken from the top, with the form lying flat on a surface. The coordinates provided (latitude: 10.289, longitude: 11.158) correspond to the location of the Gombe State Hospital Services Management Board, Specialist Hospital, Gombe, Nigeria, confirming the image location.
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