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LABORATORY TESTING REQUISITION

WILLIAM BEAUMONT ARMY MEDICAL CENTER


DEPARTMENT OF PATHOLOGY AND AREA LABORATORY SERVICES
5005 N PIEDRAS ST, EL PASO, TX 79920 (915) 569-2231

PRINT PATIENT NAME (LAST, FIRST, MIDDILE) DATE OF BIRTH (MM/DD/YEAR) SEX

PATIENT SOCIAL SECURITY # PATIENT PHONE #

ORDERING PROVIDER CLINIC/ADDRESS

FAX RESULTS TO: SPECIAL INSTRUCTIONS DIAGNOSIS PRIORITY FASTING


ROUTINE ASAP STAT Y/N
ORGAN/DISEASE PANELS OTHER TESTS OTHER TESTS ctd HEMATOLGY ctd
□ BASIC METABOLIC PANEL □ AMMONIA □ LITHIUM □ aPTT
(Na, K, Cl, CO2, Glu, BUN, Cr, Ca) □ AMYLASE □ MAGNESIUM (Mg) □ RETICULOCYTE COUNT
□ BONE PANEL □ ANA W/REFLEX TITER □ MYOGLOBIN □ SED RATE
(Ca, ALP, Phos, Alb, Uric Acid) □ ARTERIAL BLOOD GAS □ OCC BLD, FECES - GUAIAC □ SEMEN ANALYSIS
□ CARDIAC PANEL Fill in Clinical Info at bottom □ OSMOLALITY □ SICKLE SCREEN
(CK, CKMB, RI) □ AST □ Serum □ THROMBIN TIME
□ COMP METABOLIC PANEL □ BNP - B-Type Naturetic Peptide □ Urine MICROBIOLOGY
(Na, K, Cl, CO2, Glu, BUN, Cr, Ca, □ BILIRUBIN, DIRECT (DBili) □ PHENYTOIN SOURCE (REQ):_______________
TP, Alb, TBili, ALP, AST, ALT) □ BILIRUBIN, TOTAL (TBili) □ PHOSPHORUS (Phos) □ BLOOD CULTURE
□ ELECTROLYTE PANEL □ C REACTIVE PROTEIN (HS) □ POTASSIUM (K) □ BORDETELLA PERTUSSIS CUL
(Na, K, Cl, CO2) □ CALCIUM (Ca) □ PROGESTERONE □ FLUID CULTURE
□ HEPATIC PANEL □ CARBON DIOXIDE (CO2) □ PROLACTIN □ FUNGAL CULTURE
(ALP, Alb, AST, ALT, GGT, □ CEA □ PROTEIN, TOTAL □ GENITAL CULTURE
TBili, DBili) □ CHLORIDE (Cl) □ PSA, FREE □ GRAM STAIN
□ HEPATITIS PANEL, ACUTE □ CHOLESTEROL, TOTAL (TChol) □ PSA, TOTAL □ GP A STREP CULTURE
(HBsAG, HEP C AB, □ CORTISOL □ RHEUMATOID FACTOR □ HERPES VIRAL CULTURE
HEP A AB IgM, HBcAB IgM) □ CREATININE (Cr) □ RPR w/REFLEX TITER □ MRSA CULTURE
□ IRON PANEL II □ CREATINE KINASE (CK) □ RUBELLA IGG AB □ RESPIRATORY CUL - SPUTUM
(Fe, Total Fe Binding, □ CREATINE KINASE-MB (CKMB) □ PROTIEN ELECTROPHORESIS □ RESPIRATORY CUL - BAL
Unsaturated Fe Binding, □ DIGOXIN ___ Urine ___ Serum □ THROAT CULTURE
Fe Saturation, Transferrin, Ferritin) □ ESTRADIOL □ SODIUM (Na) □ WOUND CULTURE (Aerobic)
□ LIPID 5 PANEL □ ETHANOL (ETOH), Medical □ TESTOSTERONE, TOTAL □ WOUND CULTURE (Anerobic)
(TChol, Trig, HDL, calc LDL, □ FERRITIN □ TRANSFERRIN □ URINE CULTURE
calc VLDL, TChol/HDL Ratio) □ FOLIC ACID □ TRIGLYCERIDES (Trig) □ VAG/REC GP B STREP CUL
□ RENAL PANEL (WBAMC) □ FSH □ TROPONIN I □ VRE CULTURE
(Na, K, Cl, CO2, Glu, BUN, Cr) □ GENTAMICIN □ TSH □ STOOL CULTURE FOR:
□ SERUM TOXICOLOGY □ GGT □ T3 FREE □ Campylobacter
(ETOH, Acetaminophen, Salicylate) □ GLUCOSE, GEST. SCR □ T3 TOTAL □ E. Coli O157H7
□ VITAMIN B12/FOL PANEL □ GLUCOSE (Glu) □ T4 (THYROXINE), FREE □ Salmonella/Shigella
(B12, FOL) □ Glu TOLERANCE TEST ___ HR □ T4 (THYROXINE), TOTAL □ Yersinia
URINE □ HAPTOGLOBIN □ UA COMPLETE (MACRO/MICRO) □ Vibrio
□ URINE ELECTROLYTE PANEL □ HCG, QUANT □ UREA NITROGEN (BUN) □ O&P
(Na, K, Cl, Cr) □ HDL □ URIC ACID GENPROBE
□ URINE DRUG SCREEN □ HEMOGLOBIN A1C □ VALPROIC ACID □ CHLAMYDIA & GC
(Barb, Benz, Coc, Opi, Cann, Amph) □
HEP A AB IgM □ VITAMIN B12 RAPID TESTING
□ MICROALBUMIN PANEL □
HEP B CORE AB IgM HEMATOLGY SOURCE (REQ):_______________
(Microalbumin, Cr, Ratio) □
HEB B SURFACE AB □ CBC HEMOGRAM □ CLOSTRIDIUM DIFFICILE
□ CREATININE CLEARANCE □
HEB B SURFACE AG w/CONF (H/H, RBC, Indices, WBC, PLT □ CRYPTOCOCCUS
(Cr, UCr, CrCl calc) HEP C AB □ □ CBC w/DIFF □ INFLUENZA A&B ANTIGEN
□ 24 Hr Urine for ____________ IgA □ (H/H, RBC, Indices, WBC, PLT, DIFF □ RSV ANTIGEN
BLOOD BANK IgG □ □ D-DIMER □ ROTAVIRUS
□ ABO/RH IgM □ □ FECAL LEUKOCYTES (PMN) URINE ONLY
□ ANTIBODY SCR, w/REFLEX ID IRON (Fe)□ □ FIBRINOGEN □ STREPTOCOCCUS ANTIGEN
□ DIRECT ANTIGLOBULIN TEST □
LACTATE (LACTIC ACID) □ HEMOGLOBIN □ LEGIONELLA PNEUM ANTIGEN
□ PRENATAL SCREEN LDH □ □ HEMATOCRIT IMMUNOCAP
(ABO/RH, ANTIBODY SCREEN) LIPASE □ □ MIXING STUDY PT___ PTT___ □ ALLERGEN IgE TESTING
□ TYPE AND SCREEN LH □ □ PT/INR LIST ALLERGENS BELOW
ADDITIONAL TESTS: (INCLUDE AS MUCH INFORMATION AS POSSIBLE)

PHYSICIAN SIGNATURE:
WBAMC FORM xxxx JUN 06 (DPL)