Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results

Forgot Password?
Get Started
OR
Sign UpLogin With Facebook
Sign UpLogin With Google

Laboratory Requisition Form Template

Streamline Lab Test Requests with Our Easy-to-Use Template

Efficiently managing lab test requests can be a hassle, especially in high-demand healthcare settings. This laboratory requisition form template is designed specifically for medical clinics, healthcare providers, and lab technicians aiming to simplify the process of ordering tests and tracking patient progress. You'll benefit from faster turnaround times, reduced paperwork, improved patient communication, and enhanced organization-all while ensuring compliance with necessary standards like WCAG for accessibility. Explore the live template to see how it can improve your workflow.

Use this Template (FREE) Live Preview
Patient full name
Date of birth
Patient ID or medical record number (MRN)
Address (street, city, state/province, postal code)
Patient phone
Patient email
Sex assigned at birth
Female
Male
Intersex
Prefer not to say
Ordering provider full name
Practice or facility name
NPI or provider ID
Provider phone
Provider fax
Provider email
Order priority
Routine
Urgent
STAT
Other tests (specify names and codes if available)
Primary diagnosis code(s) (ICD-10)
Clinical information or indication
Tests requested
Specimen type
If other specimen type, specify
Collection date
Collection time (include time zone)
Fasting status
Yes (fasting)
No (not fasting)
Unknown
Not applicable
Current anticoagulant use
Yes
No
Unknown
Specimen collected by (name or role)
Pregnancy status
Pregnant
Possibly pregnant
Not pregnant
Unknown
Not applicable
Insurance carrier
Member ID or policy number
Subscriber name
Subscriber date of birth
Billing type
Bill insurance
Bill patient/self-pay
Bill client/facility
Medicare/Medicaid
Fax number for results
Email for results
Additional recipients or special reporting instructions
Preferred result delivery method(s)
Secure portal
Fax
Email (encrypted)
Phone call
Mail
I consent to the performance of the tests ordered on this requisition
Yes
No
I acknowledge financial responsibility for services not covered by my plan
Yes
No
Printed name of patient or legal guardian
If other relationship, specify
Date of authorization
Ordering provider name (printed)
Ordering provider authorization date
Relationship to patient
Self
Parent/Guardian
Power of Attorney
Other
Please Specify:
{"name":"Patient full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Patient full name, Date of birth, Patient ID or medical record number (MRN)","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a laboratory requisition form for FormCreatorAI article.

When to use this form

Use this form when you need to order blood work, swabs, or pathology for a patient and want clean, complete instructions for the lab. It helps primary care, urgent care, specialists, and telehealth teams capture exactly what to collect and why. Common scenarios include annual wellness panels, pre-op testing, A1C or INR monitoring, STI screening, and therapeutic drug levels. For workplace or treatment compliance, pair your request with the Urine drug screen form. If the visit also requires imaging, submit a Radiology order form in parallel. For TB screening workflows, document outcomes with the TB Skin test results form. Clear orders reduce redraws, speed turnaround, and help you deliver timely decisions.

Must Ask Laboratory Requisition Questions

  1. Which tests and panels are you ordering, including specific analytes or codes?

    Specific names and codes prevent ambiguity and ensure the lab routes and bills the request correctly. Clarity reduces add-on calls and repeat draws.

  2. What is the clinical indication or ICD-10 diagnosis supporting these tests?

    Linking tests to a diagnosis shows medical necessity and streamlines coverage. It also guides reflex testing and helps clinicians interpret borderline results.

  3. What specimen type, collection date/time, and patient preparation (fasting) apply?

    Correct tubes, timing, and fasting status protect sample integrity and accuracy. Time stamps also verify stability windows and turnaround expectations.

  4. Are there special handling or priority instructions (STAT, chilled, light-protected)?

    Clear handling and priority notes prevent degradation and delays. They help the lab triage work and meet clinical deadlines.

  5. Where should results be sent, and do you have permission to share them with third parties?

    Collect provider identifiers, fax/EMR details, and patient contact preferences to avoid routing errors. If results must be shared externally, attach a Release of information form to document consent.

More Forms

Copy/Edit Form Send to Recipients Make a Form w/AI Form Builder Must Ask Questions
  • 100% Free - No Catches
  • Collect Responses Today
  • Tailor to your Look & Feel