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Outpatient Laboratory Requistion Form
Patient Last Name:
First Name:

Middle Initial:
Sex:
Date of Birth:
SS#/HIC#:
Requesting Physician:
Patient Insurance Information:
Location:
ICD-9CM or Narrative Diagnosis
ICD-9CM or Narrative Diagnosis
1. 3.
2. 4.
Panels    
Basic Metabolic Panel
80048
BUN 84520
Calcium 82310
Co2 82374
Chloride 82435
Creatinine 82565
Glucose 82947
Potassium 84132
Sodium 84295
Comp. Metabolic Panel
80053
Albumin 82040
Alkaline Phosphatase 84075
Bilirubin, Total 82247
BUN 84520
Calcium 82310
CO2 82374
Chloride 82435
Creatinine 82565
Glucose 82947
Potassium 84132
Sodium 84295
SGOT/AST 84450
SGPT/ALT 84460
Total Protein 84155
Electrolyte Panel
80051
Sodium 84295
Potassium 84132
Chloride 82435
CO2 82374
Hepatic Function Panel
80076
Albumin 82040
Alkiline Phosphatase 84075
Bilirubin Direct 82248
Bilirubin Total 82247
SGOT/AST 84450
SGPT/ALT 84460
Total Protein 84155
LIPID Panel 80061
Cholesterol 82465
Triglycerides 84478
HDL Direct 83718
Renal Function Panel 80069
Albumin 82040
BUN 84520
Calcium 82310
CO2 82374
Chloride 82435
Creatinine 82565
Glucose 82947
Phosphorus 84100
Potassium 84132
Sodium 84295
Hgb A1C 83036
Chemsitry    
Albumin 82040
Alkaline Phosphatase 84075
Amylase 82150
Bilirubin, Total 82247
BUN 84520
Calcium 82310
Cholesterol 82465
CPK 82550
CKMB 82553
Creatinine 82565
Digoxin 80162
Dilantin 80185
Folate 82746
Glucose 82947
Iron & TIBC 83540
Lipase 83690
Magnesium 83735
Phosphorus 84100
Potassium 84132
PSA 84153
RF (Rheumatoid Factor) 84295
Sodium 84295
SGOT/AST 84450
SGPT/ALT 84460
Triglycerides 84478
Uric Acid 84550
Vitamin B12 82607
Thyroid Studies    
T3 Uptake 84479
T4 Thyroxine 84436
TSH 84443
Hematology    
CBC without Auto Differential 85027
CBC with Auto Differential 85025
Manual Differential 85007
Platelet 85595
WBC count  
Hemoglobin  
Hematocrit  
Coagulation    
PT 85610
Urinalysis    
Auto w/o Micro 81003
Priority of Testing    
  Routine
  ASAP
  STAT

 
Physicians name or Office Representative:
Additional Tests or Messages:

 

 
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