Information Requirements

Sample quality and test ordering accuracy can greatly affect the quality and outcome of processing laboratory samples. If critical information is not provided, test results may be delayed or not reported at all. In addition, billing problems can be created if necessary information is not provided completely and accurately.

Each request form should include the following:

  • Patient’s name (first and last)
  • Date and time of collection
  • Date of birth
  • Gender
  • ICD 10 Diagnosis Code(s)
  • Patient’s address and phone number
  • Source of specimen ( if pathology & microbiology requisition)
  • Date of last menses, pregnancy status, surgical history, previous abnormal paps or biopsies ( if cytology requisition)
  • Requesting physician’s phone number(s)
  • Billing/insurance information
  • Tests requested
  • Additional tests requested if needed
  • Physician/provider signature
  • AFP data sheet (specific for Alpha Feto-protein test only)


Request Forms

The following request forms are available for outreach testing:

  • Clinical Test Request Form
  • Surgical Pathology/Cytology Form
  • AFP Form