Irvine Diagnostic Laboratory - Lab Test Requisition Form
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Specimen / Sample ID
*
Provider Information
Provider Name
NPI
Submitting Site Name
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Collector / Submitted By
Signature
Test Requested
List of Tests / Panels:
*
ICD-10 Diagnosis Code(s) / Clinical Information, if applicable:
Specimen Collection Information
(To be completed at the time of collection)
Date of Collection
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Collection
Preview PDF
Submit
Should be Empty: