Follow the steps to fill out the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient information in the designated fields. This includes the last name, first name, middle initial, date of birth in mm/dd/yyyy format, and social security number.
3. Provide the patient's address, including street address, city, state, and zip code. Additionally, include a contact phone number.
4. Select the appropriate gender and race from the given options. Ensure you specify the ethnicity correctly, choosing from Hispanic/Latino or Not Hispanic/Latino.
5. Fill in the date the specimen was collected, including the time. Include the specimen ID number where indicated.
6. Check all applicable test(s) requested by indicating your selections in the Bacteriology, Parasitology, Serology, Molecular Testing, and other relevant sections.
7. Complete the patient history and clinical information by entering the clinical diagnosis, date of onset, and any surveillance details if applicable.
8. Provide your facility's information, including facility name, physician name, address, and contact details.
9. List any other significant factors that may affect the specimen or the need for testing, such as animal contact, foodborne risk, or immunocompromised status.
10. Once all sections are filled out, review the form for accuracy. After confirming all information is correct, save your changes. You may then download, print, or share the form as needed.

Complete and submit your microbiology requisition online today.