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LABORATORY/TEST REQUEST FORM
Ordering Physician
*
Required: Physician or clinician ordering the test.
Priority Level
*
Routine
Urgent
STAT
Select the urgency level for processing the test.
Tests Requested (Select all necessary laboratory tests)
*
CBC
CMP
Lipid Panel
TSH
Urinalysis
Specimen Type
*
Blood
Urine
Tissue
Swab
Date Collected
*
Required: Accurate collection time is critical for some tests.
Patient Fasting
*
Yes
No
Was the patient instructed to fast prior to collection?
Submit