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