Get Test Request Form

Filling out the Test Request Form online ensures accurate submission for testing services. This guide provides clear and concise steps to help you complete the form effectively.

Follow the steps to complete the Test Request Form with ease.

1. Press the 'Get Form' button to access the Test Request Form and open it in your chosen online editor.
2. Begin with the submitter information section. Fill in your full name, address, city, state, zip code, phone number, fax number, laboratory contact name, and their phone number for inquiries regarding the sample.
3. Proceed to the patient information section. Enter details such as the ordering physician's name, date and time of sample collection, and the patient’s name (last, first, middle initial). Fill in the patient's address, including their country of origin, city, state, zip code, date of birth, social security number, age, and sex.
4. Indicate whether the patient is pregnant by selecting Yes, No, or Unknown. Follow this by specifying the patient’s ethnicity, choosing from Hispanic, Non-Hispanic, or Unknown.
5. Next, fill in the race categories by marking the appropriate option: White, Black or African American, American Indian/Native Alaskan, Asian, Native Hawaiian/Pacific Islander, or Other.
6. Input the Patient ID number and the ICD diagnosis code. Provide the date of onset, along with the patient's diagnosis or symptoms and the location of treatment, selecting Inpatient, Outpatient, or Surveillance as applicable.
7. For immunology tests, choose between QuantiFERON In-tube or T-SPOT.TB. If choosing QuantiFERON, record the nil, antigen, and mitogen tube lot numbers. If selecting T-SPOT.TB, ensure to note the blood collection method.
8. Once all sections are completed, review the form for accuracy. Save your changes, then download, print, or share the completed form as needed.

Encourage others to complete their Test Request Form online for a smoother process.