Laboratory Requisition Form

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

                  Email

                    Test Information

                    Tests Requested

                    Select all that apply.

                      • Complete Blood Count (CBC)

                      • Basic Metabolic Panel (BMP)

                      • Comprehensive Metabolic Panel (CMP)

                      • Lipid Panel

                      • 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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