Provider Order Form (STI TESTING)

Valley Medical Laboratory

Specimen Testing Order

Lab Information:

Lab Name: Valley Medical Laboratory

Address: 2438 E 117th St, Burnsville, MN 55337

Phone: (612)444-3000 Fax: 612-444-9000
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Patient Information

Complete ALL required fields OR upload Face Sheet for a valid order
First:*
Last Name:*
Date of Birth*

MonthDayYear
Date
Sex:*
Race/Ethnicity:*
Phone Number*

Area CodePhone Number
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Carrier:*
If unknown, type "Unknown"
ID #:*
If unknown, type "Unknown"
Group #:
If unknown, type "Unknown"
Is the patient currently pregnant?*

YesNoOther
If yes, how many weeks?
If unknown, type "Unknown"
Is the patient current receiving prEP treatment?*

YesNoOther
Has the patient ever been diagnosed with HSV 1 or 2, Syphilis, or Monkeypox?*

YesNoOther
Date of first lesion (if applicable)?*
If unknown, type "Unknown"
Has the patient been in contact with anyone after developing lesions?*

YesNoOther
Ordering Provider Information

Please complete ALL fields for a valid order
Provider Name & Title:*
NPI:*
Clinic Name*
Clinic Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*

Area CodePhone Number
Fax Number*
Results may be faxed to this number
Email Address*
Provide Email Address where you would like results sent to
Order Details
Select the test(s) you wish to order (recommended to test for ALL if lesions are present)*

MonkeypoxHSV (Herpes) 1 & 2Syphilis
Primary Diagnosis (ICD10) - Exposure and/or Symptoms (REQUIRED)*
Secondary Diagnosis (ICD10) - Exposure and/or Symptoms (OPTIONAL)
Tertiary Diagnosis (ICD10) - Exposure and/or Symptoms (OPTIONAL)
Physician/Referral Provider Signature*

Clear
Order Date*

MonthDayYear
Date
When you submit this form it will be automatically sent to the Valley Medical and Wellness Laboratory to complete. Next, please select a date and time for you patient to come in for testing. Thank you!
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Patient Information

Ordering Provider Information

Order Details