A laboratory requisition form template with room for more than three tests

Read this before you print a pad

One thing matters more than anything else on this page, so it goes first. Most laboratories issue their own requisition form and many will only accept theirs — because their form carries their test codes, their specimen requirements and their account details. Before adopting any lab requisition form template, including this one, ask the laboratory you send to whether they will accept a practice-generated requisition. If they will not, use theirs and you have lost nothing. Where they will, or where you need an internal record of what was ordered before specimens leave the building, this preset gives you a properly structured document rather than a scanned page from 2011. Editable throughout, PDF immediately, no signup.

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What a lab test requisition form needs to carry

Patient identification — full name, date of birth, sex where the assay requires it, and an internal identifier — plus insurance or billing details where your workflow includes them. The ordering practitioner, which is the part labs reject most often for being incomplete: name, credentials, NPI, practice, phone and, crucially, a signature. Then the order itself. Tests requested, each on its own row with the specimen type, and the diagnosis codes your practice supplies. Collection details: date and time drawn, who drew it, fasting status, and the number of containers. Any special handling your practice has been told applies. Then a clear indication of where results should be sent and who else should receive a copy, which is the field most often left blank and most often chased afterwards.

Tests and specimens repeat, because a single panel is not the normal case

This is where the standard laboratory request form template falls down. A patient having a routine screen might need four separate assays across two tubes, and a form offering three lines forces somebody to write in the margin or produce a second requisition that gets separated from the first. Here tests repeat, one row each, with the specimen type against each. Specimen collection details repeat too, so two draws at different times are recorded as two entries rather than one ambiguous line. A laboratory test requisition form is only as useful as its ability to show precisely what was taken and when, and the same is true of any phlebotomy requisition form or requisition form for phlebotomy your draw station uses, and cramming that into a fixed grid is how mismatches between a form and a rack of tubes happen.

Edit it, then download exactly what you built

Rename the form, rewrite any label or instruction, mark fields required or optional, and add, duplicate, reorder or remove sections. Practices with a standing panel they order weekly usually pre-fill it; practices sending to two different laboratories often keep two versions with different account details. A default PDF is ready as soon as the page loads, and after any change a new PDF is generated from your current version, so what you print is what you designed. It prints on US Letter in clean black and white, which matters because these travel with specimens and get handled. Reset restores the original preset whenever you want to start again.

A two-physician practice, one morning

A small internal medicine practice draws bloods in-house twice a week and had been using the receiving lab's paper form with a photocopied second page for extra tests. They start from this preset for their own internal record. They expand the test rows to eight, having counted what a typical diabetic review actually orders. They make the ordering practitioner signature and the results-copy-to field required, because both had caused chasing. They keep the receiving laboratory's own form for what actually travels with the specimens, having confirmed the lab will not accept a substitute. One morning, and their internal record finally matches what left the building.

What the ordering practitioner decides, and what this form does not

Every clinical field here is entered by the ordering practitioner, and the form records it without adding anything. It does not suggest which tests or panels to order, propose diagnosis or procedure codes, generate a diagnosis, determine medical necessity, advise on specimen handling, collection tubes or transport conditions, or promise that any laboratory will accept the requisition or that any payer will reimburse it. Those are matters for the ordering clinician, the receiving laboratory and the payer respectively. Public health submissions — notifiable disease reporting, newborn screening and similar — run on official forms issued by the relevant authority and are not what this document is for; use theirs. This is an original document rather than a copy of any laboratory or agency form. Have your ordering clinician confirm the fields and your practice manager confirm acceptance with the lab. DocRepute is HIPAA-focused and built for HIPAA-compliant workflows, and as this is a public builder, build the blank form here rather than entering real patient details.