Free Laboratory Requisition Form Template
Laboratory Requisition Form
Please complete this form to facilitate the accurate requisition of laboratory tests and services.
Patient Information
Patient Name
Date of Birth
Gender
-
Male
-
Female
Patient ID
Address
Phone number
Physician Information
Referring Physician
Physician ID
Phone number
Test Information
Tests Requested
Select all that apply.
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Complete Blood Count (CBC)
-
Basic Metabolic Panel (BMP)
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Comprehensive Metabolic Panel (CMP)
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Lipid Panel
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Liver Function Tests
-
Thyroid Function Tests
-
Urinalysis
Clinical Information
Reason for Testing
Clinical History
Medications
Specimen Collection
Specimen Type
-
Blood
-
Urine
Date of Collection
Date:
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