Get Quicksilver Scientific Patient Requisition Form 2016-2025

Completing the Quicksilver Scientific Patient Requisition Form is an essential step in submitting your test requests. This guide provides step-by-step instructions to assist you in accurately filling out the form and ensuring a smooth process.

Follow the steps to effectively complete your Patient Requisition Form.

1. Press the ‘Get Form’ button to access the form and open it in the designated editor for filling.
2. Begin filling out the patient information section. Clearly indicate which test you are submitting by checking the appropriate box for either the Mercury Tri Test or the Blood Metals Panel. You may select both tests if it applies to the same patient.
3. Complete all personal information fields, including your first name, last name, middle initial, gender, address, city, state or province, zip code, country, phone number, date of birth, email, age, weight, and occupation. Ensure the email address is accurate as results will be sent here.
4. Indicate your dietary habits by specifying the average number of fish meals per month and if you are taking any metal supplements or antipsychotic medications. Additionally, disclose any history of dental amalgams, whether removed, and any other potential sources of metal exposure.
5. In the practitioner information section, provide your practitioner’s signature, name, practice, NPI/state license number, and address. Specify where you would like the results to be sent, either to the patient or the practitioner.
6. Complete the payment information section by selecting who will be responsible for the payment and providing credit card information or alternative payment methods. Fill in the billing zip code, security code, expiration date, and sign if required.
7. Fill out the specimen collection information section, indicating the types of samples being submitted and ensuring blood and urine samples are collected within the same 24 hours, when applicable.
8. Review all information provided for completeness and accuracy. Once satisfied, you can save changes, download, print, or share the completed form as necessary.

Complete your Quicksilver Scientific Patient Requisition Form online today for seamless test processing.