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

Medical Requisition Form Template

Streamline Your Medical Equipment Requests Effortlessly

Submitting medical requests can often lead to confusion and delays in patient care. This template helps healthcare professionals efficiently request medical equipment, supplies, and medications, ensuring timely support for your patients. With clear fields for essential information, easy customization for specific needs, improved accuracy in orders, enhanced communication with suppliers, and compliance with medical guidelines, you can streamline your requisition process. Explore how this ready-to-use template can simplify your workflow.

Use this Template (FREE) Live Preview
Patient full name
Date of birth
Patient phone
Patient email
Address (street, city, state, ZIP)
Patient ID or MRN
Sex for lab reference ranges
Female
Male
Unknown/Not specified
Insurance provider
Member ID
Group number
Responsible party for billing
Patient
Insurance
Employer/Facility
Other
Please Specify:
Pre-authorization number (if applicable)
Pre-authorization obtained
Yes
No
Ordering provider full name
NPI (National Provider Identifier)
Ordering facility or practice
Provider phone
Provider fax
ICD-10 diagnosis code(s)
Clinical notes or indication
Fasting required for this order
Yes
No
If fasting, hours fasted
Pregnancy status
Pregnant
Not pregnant
Unknown
Not applicable
Other tests requested (names or codes)
Tests requested
Specimen type
Please Specify:
Collection date
Collection time
Number of containers or tubes
Collection location
In clinic
Patient home
External laboratory
Hospital
Other
Please Specify:
Special handling requirements
Refrigerate
Freeze
Room temperature
Protect from light
Ship on ice
Keep upright
None
Courier pickup required
Yes
No
Order priority
Routine
Expedited
STAT
Primary results recipient name
Results recipient fax
Results recipient email
Additional recipients or notes
Preferred results delivery method
Fax
Secure email
Provider portal
Phone call
I authorize the laboratory to perform the tests ordered and bill as indicated
Yes
No
Patient or legal guardian name
Date of patient authorization
Ordering provider name
Date of provider acknowledgment
I confirm the medical necessity of the tests ordered
Yes
No
{"name":"Patient full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Patient full name, Date of birth, Patient phone","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a medical requisition form for FormCreatorAI article

When to use this form

Use this form when you need to order tests, imaging, or procedures from a lab or department. Clinicians, nurses, and front-desk staff use it after a visit to route orders and set priority. Example: a primary care visit ends with orders for a CBC, CMP, and a chest X-ray; you submit this with clinical notes and timing. For imaging orders, pair it with the Radiology order form. For employment or school screenings, you can record results in the TB Test results entry form. For pandemic protocols, collect exposure and travel details first using the Coronavirus-19 health declaration form. The outcome: clear instructions, fewer call-backs, faster turnaround, and traceable requests.

Must Ask Medical Requisition Questions

  1. What specific test, imaging study, or service are you requesting (include CPT or internal codes if known)?

    Clear names and codes tell the receiving team exactly what to perform, reducing back-and-forth. Precision here prevents wrong or incomplete orders.

  2. What clinical indication, diagnosis, or symptoms support this request?

    This shows medical necessity and helps the department choose the right protocol. It also supports coverage decisions and appropriate triage.

  3. What is the priority and required-by date/time (routine, urgent, or STAT)?

    Stating urgency helps the team schedule and process your request on time. It also documents risk if the service is delayed.

  4. What are the patients full name, date of birth, identifiers, and contact details?

    Accurate identity prevents mix-ups and ensures results reach the right person. Adding MRN or insurance ID speeds verification and follow-up.

  5. Do you have recent results or records to reference or attach?

    Prior data avoids duplicate testing and guides interpretation. If proof of record status is required, note or link supporting documents with a Medical record certification form.

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