Lab Requisition Form
This is a form that is important as it accompanies each supply that is submitted to the lab. This form contains the proper information in order to process the specimen and ensure that all tests are properly done. It’s a complete list of lab tests that are important and relevant.
Sample Lab Requisition Form
Patients Information
Surname: _______________ First Name: _____________Middle name: _____________
Date of Birth: _________________________ Sex: _____________________________
Patients ID No : _____________________ Social Security No. ___________________
Date of Collection
Date collected: __________________ Time collected: ________________________
Mail results to P.O # _____________________________________
Diagnosis: _________________________________________________
Referring physician: ____________________Specialty:______________________
Physician PIN: ___________________________ Location: ____________________
Secure Fax for lab results: __________________________________
Physicians No: ___________________________ Facility No: _____________________
Billing Address
(Please Bill)
Medicare: ______________ Check: ___________________________
Patient (pre-pay):______________________ Money order: ________________
Visa: _______________________
Person Paying
Last Name: __________________ First Name: ____________________
Address: _______________ City: _________________ State: ______________
Zip: ____________________
Telephone Number: ________________________
Test Requested: _____________________________________
Comments: _________________________________________
Category: Requisition Forms
