Blood Culture Collection Order Form
Submit a request for blood culture collection with all required patient and collection details.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
Date
Medical Record Number
*
Ordering Physician Name
*
First Name
Last Name
Ordering Department / Unit
*
Contact Phone Number (Physician or Department)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Clinical Indication for Blood Culture
*
Please Select
Fever of Unknown Origin
Suspected Sepsis
Chills/Rigors
Endocarditis
Other
Date and Time of Collection
*
 -
Month
 -
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Collection Site
*
Please Select
Left Arm
Right Arm
Central Line
Port
Other
Number of Sets Ordered
*
Name of Person Collecting Specimen
First Name
Last Name
Specimen Handling Instructions
Send to Lab Immediately
Special Handling Required
Notify Physician of Positive Result
Additional Notes or Special Instructions
Submit Order
Should be Empty: