Blank Hospital Lab Report Note

Patient Information:

  • Patient Name:                            

  • Patient ID:                            

  • Date of Birth:                            

  • Gender:                            

  • Admission Date:                            

  • Physician:                            

Lab Information:

  • Lab Name:                            

  • Lab Address:                            

  • Lab Phone Number:                            

  • Report Date:                            

  • Specimen Type:                            

  • Date/Time Collected:                            

Test Results:

Test Name

Test Code

Result

Reference Range

Units

                           

                           

                           

                           

                           

                           

                           

                           

                           

                           

                           

                           

                           

                           

                           

                           

                           

                           

                           

                           

Interpretation:

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      

Recommendations:

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      

Signature:

Technologist Name:                                    
Technologist ID:                                    
Date:                                    

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