Lab Requisition Form
Virtuous Healthcare Practice
Quest Lab Submission Form
Name of Patient
First Name
Last Name
Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Sex at birth
Please Select
Male
Female
Specimen Information
What type of Labs would you like drawn?
CMP
BMP
Lipid Panel
Liver Panel
Liver Function
Hemoglobin A1c
TSH
Free T4/Free T3
Testosterone
Estradiol/Progesterone
Cortisol
Parathyroid Hormone (PTH)
Vitamin D (25-Hydroxy)
HIV 1/2 Ab/Ag
Vitamin B12/Folate
Hepatitis Panel (A,B,C)
Iron/Ferritin/TIBC
Hepatitis Panel (A,B,C)
Covid-19 PCR/Ab
ANA / Autoimmune Panel
Urine Drug Screen
Heavy Metals Panel
STI Panel
Pregnancy Test (Urine/ Serum)
Other
Reasons for the Labs / Include the diagnosis code
Urgency
Please Select
3-5 days
STAT
Any needed Vaccines during nurses visits
Influenza (Flu Vaccines)
COVID-19 Vaccine
Tdap (Tetanus, Diphtheria, Pertussis) One dose at age 11-12 than a booster every 10 years
HPV (Human Papillomavirus)
MCV4 (Meningococcal ACWY)
MenB (Meningococcal B) Optional, ages 16 - 23 based on risk
Hep A - 2 dose series if not completed earlier
Hep B - 3 dose series if not completed earlier
MMR (Measles, Mumps, Rubella) - Ensure 2 doses have been given
Varicella (Chicken Pox) - Ensure 2 doses have been given
Polio (IPV) - Ensure series is complete
Pneumococcal (PPSV23 or PC 15TH/20) FOr high risk patients only chronic conditions
Travel Vaccines
Additional Clinical Information
Submit
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