VirtuCare Harmony Lab Requisition Form

VirtuCare Harmony Lab Requisition Form
Name of Patient

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Sex at birth
Specimen Information
CMPBMPLipid PanelLiver PanelLiver FunctionHemoglobin A1cTSHFree T4/Free T3TestosteroneEstradiol/ProgesteroneCortisolParathyroid Hormone (PTH)Vitamin D (25-Hydroxy)HIV 1/2 Ab/AgVitamin B12/FolateHepatitis Panel (A,B,C)Iron/Ferritin/TIBCHepatitis Panel (A,B,C)Covid-19 PCR/AbANA / Autoimmune PanelUrine Drug ScreenHeavy Metals PanelSTI PanelPregnancy Test (Urine/ Serum)Other
Reasons for the Labs / Include the diagnosis code
Urgency
Influenza (Flu Vaccines)COVID-19 VaccineTdap (Tetanus, Diphtheria, Pertussis) One dose at age 11-12 than a booster every 10 yearsHPV (Human Papillomavirus)MCV4 (Meningococcal ACWY)MenB (Meningococcal B) Optional, ages 16 - 23 based on riskHep A - 2 dose series if not completed earlierHep B - 3 dose series if not completed earlierMMR (Measles, Mumps, Rubella) - Ensure 2 doses have been givenVaricella (Chicken Pox) - Ensure 2 doses have been givenPolio (IPV) - Ensure series is completePneumococcal (PPSV23 or PC 15TH/20) FOr high risk patients only chronic conditionsTravel Vaccines
Additional Clinical Information
Should be Empty:

Specimen Information