Lab Requisition Apply Patient Label

Lab Requisition Routine Stat ASAP Timed

Apply Patient Label

Collection Date/Time: Collected by (Emp ID #): PATIENT DIAGNOSIS: ________________________

Profiles Blood BankElectrolytes (Na, K, Cl, CO2) Type & Screen Date Needed:BMP (Lytes, Glu, BUN, Creat, Ca) Type & Crossmatch # UnitsCMP (BMP, TP, Alb, AST, ALT, ALP, TBil) Platelets # UnitsHepatic Function (ALB, AST, ALT, ALP, T bili, D bili, TP) w/GGT Plasma # UnitsLipid (Chol, Trig, HDL, LDL, VLDL) Other: # UnitsRenal Function (Alb, CA, Na, K, Cl, CO2, Creat, Gluc, Phos, Bun)Acute Hepatitis (Hep A IGM, HBS Ag, Hep B Core IgM, Hep C Ab )

Special Requirements

DIC Panel (PT, INR, PTT, Fib, TT, Plt, RBC frag, D-dimer) ReasonIron Profile w/ Ferritin (Iron, TIBC, UIBC, % sat, Ferritin)

Chemistry Therapeutic Drugs

Therapeutic Drugs Hematology Spinal/ Body FluidsAmmonia Cyclosporine CBC w/diff, reflex to manualAmylase Gentamicin CBC, hemogram only

Body Fluid Source

Bilirubin, Direct Hematocrit CSF Exam (cell ct, gluc,T protein)Bilirubin, Total

Methotrexate Last dose: Hemoglobin Cell count Tube #

CK Mycophenolic acid w/ metab. Platelet Count Glucose Tube #BUN Phenobarbital Reticulocyte count T Protein Tube #Cortisol AM, PM, Rndm Sirolimus Sed Rate LDH Tube #CRP (C-Reative protein) Tacrolimus (FK506) Special Hematology Amylase Tube #Ferritin Tobramycin MicrobiologyGGT Valproic Acid

Clinical History required; indicate in Comments section

Hemoglobin A1C Urine Tests

Vancomycin Path Smear/ReviewSpecimen Source:

Immunoglobulins A G M Flow Cytometry, if indicated Culture type (indicate below)Iron TIBC Urine Tests Bacteria Cult/Gram StainLactic acid Urinalysis (w/ microscopic) Fungus Cult/StainLDH Urine Culture & Sensitivity Coagulation AFB Cult/StainLipase Urine Pregnancy Test Protime Viral Cult(use viral transport media)Magnesium PTT MRSA Screen [MRSASC]

Osmolality, serum Drug Testing FibrinogenMRSA/MSSA Pre-OP Screen [STAPHS]

Phosphorus Drug screen, urine (in-house) Heparin XA Culture, Beta StrepPotassium Drug screen, meconium Serology Strep Screen/RapidPro-BNP Comp drug screen (send-out) Cocci Screen (IgG/IgM) C. difficile antigen & toxinProcalcitonin EBV Early Antigen Stool pathogen panel, PCRSodium EBV Nuclear Antigen O&P (Trichrome & Concentration)T4, Free

PCR Testing (Quantitative), onplasma (unless otherwise noted) EBV Viral Capsid, IgG Occult Blood

Triglycerides Adenovirus EBV Viral Capsid, IgM Smear for PolysTroponin BK Virus urine HIV Ag/Ab Respiratory PCR PanelTSH CMV Rubella IgG Legionella PCRUric acid Epstein-Barr (EBV) Rubeola IgG Bordetella PCR Panel

HHV-6 Rotavirus AgHerpes Virus 1/2 Varcella, Zoster-Imm, Screen COVID-19 (send-out)

Other Tests -- Comments -- Clinical History MUST COMPLETEOrdering Practitioner: _________________________________ (PRINTED NAME)Practitioner Signature: ________________________________

Date: ____________________ Time: ____________________

Contact/Pager #: _____________________________________

FOR REFERENCE LAB SPECIMENS RECEIVED IN THE LAB AFTER NOON, SAME-DAY SHIPPING CANNOT BE GUARANTEED

General Laboratory Requisition PCH6102 QMS.FORMS 1 Version 1.1 Approved and current Effective starting 3/30/2020 Last reviewed: 3/30/2020