Lab Requisition Form Template

Our lab requisition form’s primary purpose is for healthcare providers to request medical tests or procedures officially. A doctor or the medical facility typically fills in the form before being processed by the desired laboratory. 

Check out our lab requisition form below:

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PATIENT DETAILS

CLINIC INFORMATION

SPECIMEN INFO

FFPE (tumor content %)

PATIENT INSURANCE PROVIDER

FINAL STEPS

My signature signifies a Certificate of Medical Necessity and certifies that I am the patient's health care provider.
You hereby agree to the medical institution's terms and conditions.

Can I Edit This Template?

As with every WPForms template, this form is 100% customizable. We’ve got the lab requisition form started with the following fields:

  • Patient details
  • Clinic and physician details
  • Specimen and requested test/procedure info
  • Patient insurance details
  • Terms and conditions and signature fields

Due to each medical institution requiring different information, we’ve kept the fields general. But feel free to edit and modify this template to fit your requirements.

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