Labcorp Requisition Form
A Labcorp requisition form is a document which allows an individual to provide a sample of his bodily fluids to a doctor for it to be tested by Labcorps. It is a permission form, which requires meticulous filling in by the individual as well as the licensed healthcare official who shall receive the sample from the patient. Such a form is a legal document, indicating that the individual has read and understood the terms and conditions which govern such transfer of medical samples. The form must thus be filled in extremely carefully, and all important details regarding the sample and the purpose for its testing must be mentioned in the Labcorp requisition form.
Sample Labcorp Requisition Form:
Labcorp Requisition Form
Date of submission of Labcorp requisition form: _____________________________[dd/mm/yy]
Labcorp requisition form submitted by: __________________________________
Address: _______________________________________ [with pin code]
Officiating health officer, in charge of collecting and submitting sample to Labcorp: _______________________________
Medical designation: __________________________________
Official address: ______________________________________
Nature of sample collected from the applicant: _________________________________
Quantity of sample collected: ________________________________________________
Purpose of testing sample: _______________________________
Specific tests to be performed on collected sample [this must be entered by the presiding health officer]: _____________________________________________
Date of receiving test reports: ____________________________________
Test reports to be collected from: _________________________________
Special precautionary measures to be taken while collecting sample [to be filled in by presiding medical officer]: _______________________________________________
[For official use only]
Time of receiving sample: __________________________________
Labcorp officer receiving sample: ____________________________
Sample ID number: _______________________________________
Other comments: __________________________________________
Signature of applicant: ________________________________________
Date: ______________________________________________________
Category: Requisition Forms
