Patient's name
Medical record number
Date/time of collection
Initials of person collecting the specimen

Blood Bank specimen need 2 inititals

Note: Consult individual test requirements for special labeling requirements.

Patient's full name (last, first)
Patient's medical record number (if available)
Patient's location
Patient's age and sex
Physician's full name
Test(s) requested: Check the box to the left of the test on the requisition. For tests not listed on the form legibly, print name of ordered test on the blank lines.
Diagnosis and/or ICD-9 code
Date and time of specimen collection

• Note any special instructions (fasting, preoperative, etc)
• Stat identification: Write "STAT" on requisition in red; or affix a STAT label to the requisition; or use a Blood Test Stat requisition
• Microbiology requests must identify the type of specimen submitted and the anatomical site (source) of specimen collection. Antibiotics administered must also be indicated.
• Creatinine clearance requests must state the patient's height and weight.
• Cytogenetic study requests must be accompanied by a completed Patient History Form. Forms are available from Cytogenetics, ext 26298.
• Drug levels must have time of drug dose

Each inpatient nursing station is stocked with laboratory requisitions by the Laboratory Liaison Technicians (LLT) assigned to the unit. Outpatient, physicians office, and client areas may obtain requisitions from LSS as stated above.