SPECIMEN PICKUP REQUEST
Date
-
Month
-
Day
Year
Minutes
AM
PM
AM/PM Option
Type of Pickup:
*
Routine Pickup
Stat Pickup
Client Name:
*
Person Taking Call
*
Person Requesting Pickup:
*
Requested Pickup Time:
*
Minutes
AM
PM
AM/PM Option
Confirmation #: (Give to Client)
STAT REPORT
Print stat report prior to submitting the form
PICKUP CONFIRMATION #
PATIENT NAME
*
PHYSICIAN
*
PHONE
*
FAX
DISPATCHED TO
*
DISPATCHED TIME
Minutes
AM
PM
AM/PM Option
SPECIAL INSTRUCTIONS
STAT TESTS REQUESTED:
1.
*
2.
3.
4.
5.
6.
7.
8.
Additional Information:
Confirmation# to Monday
Print Stat Report
Submit Pickup
Should be Empty: