Phlebotomy Lab Order Form
Submit a request for a phlebotomy lab specimen collection. Please complete all required order details.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Ordering Provider Name
*
First Name
Last Name
Provider Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Collection Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Specimen Type
*
Please Select
Blood
Urine
Saliva
Other
Tests Ordered
*
Complete Blood Count (CBC)
Basic Metabolic Panel (BMP)
Lipid Panel
Hemoglobin A1c
Thyroid Panel
Other
Clinical Indication or Notes
Ordering Location
*
Please Select
Outpatient Clinic
Inpatient Unit
Emergency Department
Home Visit
Other
Submit Lab Order
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