Customize the Lab Requisition Form Template

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PATIENT DETAILS

Date

Patient Name

First

Last

Date of Birth

Sex

Cell Phone Number

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

CLINIC INFORMATION

Clinic Name

Clinic Contact Number

Clinic Email

Clinic Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Physician Name

First

Last

SPECIMEN INFO

Date Collected

Specimen Source

Number of Samples

ICD-10 Code

KCD-10 Code

Primary Diagnosis

Secondary Diagnosis

Specimen Type

FFPE (tumor content %)

Date of Diagnosis

FFPE Tissue

I will arrange specimen shipment
Contact pathology lab for sample

Histology

Targeted Therapies

Immunotherapies

Additional Treatment Procedures

PATIENT INSURANCE PROVIDER

Group Number

ID Number

Subscriber

Employer

Date of Birth

#SS

FINAL STEPS

Test Authorization & Medical Consent

I hereby certify the following:

My signature signifies a Certificate of Medical Necessity and certifies that I am the patient's health care provider.

Physician Signature

Patient Terms and Conditions

I agree to the following:

You hereby agree to the medical institution's terms and conditions.

Patient Signature

Additional Questions or Comments

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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:

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.

Our form templates let you create any kind of WordPress form in a few clicks.

You can select any template to view the demo and try it out. If it works for you, you can import it and publish it in minutes. Each WPForms template is fully customizable too. Our drag and drop form builder makes it easy to adapt any template to fits your business’ needs. When you use our form templates, you can easily:

Lab Requisition Form Template

PATIENT DETAILS

CLINIC INFORMATION

SPECIMEN INFO

PATIENT INSURANCE PROVIDER

FINAL STEPS

Can I Edit This Template?

Our form templates let you create any kind of WordPress form in a few clicks.

Import Any Template With 1 Click

Add or Remove Fields

Customize Notification Settings

Change the Confirmation Message

Change the Field Labels

Change the Notification Email

Customize the Submit Button

Publish Your Form With Ease

PATIENT DETAILS

CLINIC INFORMATION

SPECIMEN INFO

PATIENT INSURANCE PROVIDER

FINAL STEPS

Can I Edit This Template?

Looking for something else?

Our form templates let you create any kind of WordPress form in a few clicks.

Import Any Template With 1 Click

Add or Remove Fields

Customize Notification Settings

Change the Confirmation Message

Change the Field Labels

Change the Notification Email

Customize the Submit Button

Publish Your Form With Ease