LAB TEST REQUEST FORM

User Guide: Lab Test Request Form

Overview

This Lab Test Request Form is a digital tool that allows healthcare providers to request laboratory tests for patients. The form is designed to be user-friendly, comprehensive, and printable for physical records.

How to Use the Form

1. Accessing the Form

• Open the form in any modern web browser (Chrome, Firefox, Safari, Edge)
• The form will load ready for data entry

2. Filling Out the Form

The form is divided into several sections:

Patient Information Section

• Patient Full Name (required): Enter the patient's complete legal name
• Date of Birth (required): Select the patient's birth date using the date picker
• Gender (required): Select from the dropdown menu
• Patient ID/MRN: Enter the patient's medical record number if available
• Address: Enter the patient's complete address
• Phone Number & Email: Provide contact information

Physician Information Section

• Physician Name (required): Enter the requesting physician's full name
• NPI Number: Enter the physician's National Provider Identifier
• Office Phone & Fax: Provide contact information
• Clinic/Facility Name: Enter the name of your practice or facility
• Clinic Address: Enter the complete address of your facility

Test Information Section

• Request Date (required): Select the date of the request
• Priority: Select the urgency level (Routine, Urgent, or STAT)
• Clinical Information: Provide relevant clinical details or reason for testing
• Requested Tests: Check all applicable tests
  • If selecting "Other Tests," specify in the text field provided

Insurance Information Section

• Insurance Company: Enter the patient's insurance provider
• Policy Number & Group Number: Enter the patient's insurance details

Authorization Section

• Signature (required): Provide an electronic signature
• Date (required): Select the current date

3. Form Actions

• Print Form: Click this button to print a physical copy of the completed form
• Clear Form: Click this button to reset all form fields and start over

4. Printing the Form

• The form is optimized for printing with a clean, professional layout
• When printed, only the form content will appear (navigation buttons will be hidden)
• Ensure your printer has paper before printing

Important Notes

• Fields marked with a red asterisk (*) are required
• Double-check all information before printing
• For questions, contact the laboratory at (555) 123-4567
• This form is for laboratory test requests only

Technical Requirements

• A modern web browser with JavaScript enabled
• For optimal experience, use a screen resolution of 1024x768 or higher

Troubleshooting

• If the form doesn't display correctly, try refreshing the page
• Ensure your browser is updated to the latest version
• If printing issues occur, check your printer settings and paper supply

This digital form replaces paper-based requests, making the test ordering process more efficient while maintaining all necessary information for laboratory processing.