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To download our LAB REQUISITION, click here.

Use a Black or Blue ballpoint pen, write or print legibly and firmly.  Each requisition must have the following information:

Patient Sample Information

Complete first and last name

Social Security number (SS#) is a must if patient has Medicare or Medicaid, medical record number (MR#), or other patient identification number, if available.

Collection date and time

Specimen collection details – FNA washout, serum, plasma, whole blood, or urine.

Address and phone number (if available)

DOB (date of birth)


Test request(s)

ICD-10 Code (Diagnosis code)

Billing Options (one of six) must be clearly marked
For the Insurance option, front and back copies of all insurance cards/information should be provided.  Alternatively, information should be printed legibly on the requisition including name of the insurance company, an address, phone number and group number.

Referring Physician’s name, NPI number, and phone number
In order to insure positive identification and preserve maximum integrity of patient samples from the time of collection until testing and reporting have been completed, specimens should be labeled with the patient’s first and last name or a unique identifying number.  The name or ID number on the requisition must match the name or ID number on the specimen(s).  Any labeling discrepancy will delay processing of the tests ordered and may lead to cancellation of the request.  Clients will be notified of inappropriately labeled specimens.


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