Lab Test Request Form

This form is used by healthcare providers to document and request laboratory tests for a patient. It ensures accurate information is communicated to the laboratory for diagnostic or monitoring purposes.

Patient Information

Full Name: {fullName}

Date of Birth: {dateOfBirth}

Gender: {gender}

Contact Number: {contactNumber}

Patient ID: {patientID}

Requesting Provider Details

Provider Name: {providerName}

Department/Clinic: {clinic}

Contact Number: {providerContact}

Email Address: {providerEmail}

Date of Request: {requestDate}

Test(s) Requested

Please see the list below for requested laboratory tests:

{#tests}

• {testName}: {testDescription}

{/tests}

Clinical Information

Clinical Diagnosis / Reason for Test:

{clinicalReason}

Additional Instructions for the Laboratory:

{labInstructions}

Insurance Information

{#hasInsurance}

Insurance Provider: {insuranceProvider}

Policy Number: {policyNumber}

{/hasInsurance}

{^hasInsurance}

No health insurance provided.

{/hasInsurance}

Specimen Information

Signatures

Provider Signature: ___________________________

Date: {signatureDate}