Clinical Pathology Test Order Forms

Requisition Forms

• General Requisition
• Chemistry
• Coagulation, Thrombosis and Bleeding Work Up
  • Coagulation Patient Clinical History Form
  • Thalassemia Clinical Data Sheet (Thalassemia Reflexive testing order)
• Genetics
  • Genetics, Exome/NCGL
  • For further Genetics order forms, please see our Genetics and Solid Tumor Diagnostic Testing guideline.
• Hematopathology (Morphology, Flow Cytometry, Molecular, Cytogenetics) for outside clients
• Immunology
  • Allergy Testing
  • Merkel Cell Carcinoma Serology
• Microbiology
• Molecular Diagnostics - Microbiology
• Toxicology
• Virology
  • SARS-CoV-2 (COVID-19) Test
  • HSV Western Blot Test

Employee Health Forms

• Campus Health Exposure Follow-Up
• Campus Health Non-Exposure
• Employee Screening
• UWMC Emergency Dept. Exposure Follow-Up

Submitting Requests for Tests

Submission of requests for laboratory testing should be accompanied by the appropriate requisition form. Laboratory procedures are performed ONLY upon a physician's written request. All verbal requests for additional test requests to be added to a written order must be followed by written confirmation within 30 days. CLIA-88, and thus the Joint Commission and the College of American Pathologists (accrediting agencies) require that each requisition form for laboratory services must clearly identify:

• Patient name, sex, birth date, include unique ID number, lab reference number
• Collection date and time
• Diagnosis Code
• Type of specimen submitted, indicate serial and timed collection
• Patient fasting conditions (if applicable)
• Interval and total volume if a timed urine collection
• Source of specimen if for Microbiology or Virology test(s), or other comments in "comments" box
• Authorization for laboratory work, include the name of the ordering physician and UPIN in addition to the name and address of the facility to which the results will be sent
• Check test(s) requested. If the Department of Laboratory Medicine offers a procedure that does not appear on the request form, print plainly the full name of the test desired in the space marked "OTHER REQUESTS".

Directions

1. Complete a separate requisition for each patient.
2. Please provide all information on the left hand side of the requisition form.
3. Fold completed request form and place in the outside pocket of the Specimen Bag. If submitting more than one specimen per patient, and specimens need to be stored and transported at different temperatures, use separate bags and Test Request forms for each temperature type.
4. Special requests for testing should be noted on the requisition.

Also check out our Using Our Laboratory Services guideline for labeling, shipping, and packaging specimens, contact info and other helpful details about collecting and sending specimens.