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Laboratory Requisition
Patient Name
First
Middle
Last
Date of Birth
Month
Day
Year
Physician's Signature
Date
Month
Day
Year
General Chemistry
General Chemistry
Acid Phosphatase
ALT
Albumin
ALP
Ammonia
Amylase
AST
Bilirubin, Direct
Bilirubin, Total
Calcium
Carbon Dioxide
Chloride
Cholesterol
Creatine Kinase
Creatinine
Free T3
Free T4
T Uptake
Total T4
TSH
CRP
Glucose
HS Tronponin I
BNP
Cardiac
D-Dimer
HDL Cholesterol
hCG, Quantitative
hCG, Qualitative
Iron
Lactate Dehydrogenase
LDL Cholesterol
Lipase
Magnesium
Microalbumin
Phosphorus
Potassium
Sodium
Total Iron Binding Capacity
Total Protein
Total PSA
Total Protein, CSF/Urine
Triglycerides
Urea Nitrogen (BUN)
Uric Acid
24 HR Urine, Creatinine Clearance
24 HR Urine, Total Protein
24 HR Urine, Microalbumin
Glucose Tolerance Test
Chemistry Panels
Chemistry Panels
Basic Metabolic Panel
Complete Metabolic Panel
Renal Panel
Liver Panel
Lipid Panel
Iron Panel
Thyroid Panel
Panel 1 (TU, T4, TSH)
Panel 2 (TU, T4, TSH, FT4)
Panel 3 (TU, T4, TSH, FT3)
Panel 4 (TSH, FT4)
Toxicology
Toxicology
Carbamazepine
Digoxin
Gentamicin
Lithium
Phenobarbital
Phenytoin
Theophylline
Valproic Acid
Vancomycin
Acetaminophen
Ethyl Alcohol
Salicylate
Urine Drug Screen
Rapid Infectious Disease
Rapid Infectious Disease
Rapid COVID AB
RSV
Influenza A/B
Anti-HIV 1/2
Molecular Diagnostic Testing
Molecular Diagnostic Testing
CT/GC
Trichomonas
COVID-19 RT-PCR
HPV
Coagulation
Coagulation
PT/INR
PTT
Transfusion Medicine
Transfusion Medicine
ABO/Rh Typing
Type & Screen
Crossmatch
RHOGAM Studies
Coombs Test
Fetal Blood Screen
Hematology/Urinalysis
Hematology/Urinalysis
CBC without Diff
CBC with Diff
Reticulocyte Count
ESR
Manual Blood Smear
Manual Blood Diff
Manual Body Fluid Cell Count
Malarial Smear
Platelet Estimate
Hemoglobin & Hematocrit (H&H)
UA with Microscopic
Microbiology/Parasitology
Microbiology/Parasitology
Urine C&S
Blood C&S
Body Fluid C&S
Abscess C&S
Wound C&S
Respiratory C&S
Nasal Culture
Fungal Culture
CSF C&S
Gram Stain
Wet Prep
G/C C&S
Vaginal C&S
AFB Stain
Pinworm Exam
Ova & Parasite Smear
Stool C&S
Stool Culture Panel
Rapid C. diff Ag/Toxin
Rapid Shiga Toxin A/B
Rapid S. pneumoniae Ag
Rapid Legionella Ag
Fecal Leukocyte
India Ink
Urine C&S Source
Bodily Fluid C&S Source
Abscess C&S Source
Wound C&S Source
Respiratory C&S Source
Fungal Culture Source
Gram Stain Source
Vaginal C&S Source
Serology
Serology
Rheumatoid Factor
Mononucleosis
ASO
RPR
SARS-COV-2 Total Antibody
Histology/Pathology
Histology/Pathology
Cervical Pap Smear
Tissue Biopsy
Source
Other
Other Lab Type
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