HIV Monitoring Lab Request Form
Submit a request for HIV monitoring laboratory tests. Please complete all fields to ensure accurate lab coordination.
Requester Full Name
*
First Name
Last Name
Requester Email Address
*
example@example.com
Requester Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Initials or Unique Code (do not use full name or sensitive identifiers)
*
Ordering Provider Name
*
Select HIV Monitoring Tests Requested
*
HIV-1 RNA (Viral Load)
CD4 Count
HIV Genotype Resistance
HIV Phenotype Resistance
Other
Specimen Type
*
Please Select
Plasma
Serum
Whole Blood
Dried Blood Spot
Other
Specimen Collection Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Priority
*
Routine
Urgent
Preferred Result Delivery Method
*
Secure Email
Phone Call
In-person Pickup
Additional Lab Instructions (optional)
Submit Request
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