LABORATORY REQUEST FORM

Specimen Collected Patient Details Insurance info ICD-9

code
By: Name:
Date: Address:
Time: Telephone number: 272.4
Date of Birth:
Gender:
Ordering Contact Info (Critical Copies Office Facility and unit
Physician/NP: Results)

Sample details
Urgency: Normal Sample taken from patient:

URGENT Date: (dd/mm/yyyy)

Time: (hh/mm)
Fasting Non-fasting

Relevant clinical information:

Drug therapy: Last dose:
Date: (dd/mm/yyyy)
Time: (hh/mm)
Other relevant clinical
information/comments:

CHEMISTRY CARDIAC FUNCTION AND LIPIDS

1 Yellow SST Tube (Glucose, fasting or random
requires a gray tube and certain tests, special tubes as indicated)
Glucose- Fasting Alk Phos - ALP Calcium - Ionized HS-CRP - Cardiac BNP (Purple Tube) Troponin (Green
Glucose- Random ALT Osmolality Tube)
Creatinine - eGFR GGT Uric Acid - Urate
Calcium - Total Lipase Magnesium Lipid Profile: Cholesterol, LDL, HDL & Triglycerides
Total Protein Serum Pregnancy (+/-) Phosphate Total cholesterol
Albumin Bilirubin - Direct Lactate (Green on Triglycerides (Fasting Only)
Total Bilirubin Ammonia (Green on Ice)
Ice) Fasting Non-Fasting
e HEMATOLOGY BLOOD GASES
One purpe tube (EDTA) add one red for mono screen Collect in a Heparinized Syringe, Send on Ice Blood Gases should be the
only order on the requisition to aid processing
CBC and auto diff Kleihauer Specimen Arterial Capillary Central/Mixed Venous
A1C Mono screen Venous (Green Tube, no Gel on Ice)
Reticulocyte count Cord (Send Cord on Ice)
Urinalysis SPECIAL CHEMISTRY
Routine Urinalysis Glucose Iron Urine Protein Electrophoresis
Microscopic Semen Analysis Ferritin Hgb A1C
Specific Gravity Post Vas Thyroid Screen CK-MB
Hep A- Antibody PAP
Hep C- Antibody HCG (Serum Screen)
Serum Protein Electrophoresis HCG Quantitative
Additional Request: (Please Contact Lab for Special Instructions and Requester’s signature:
Availability)