Laboratory Requisition Form
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1LABORATORY REQUISITION
Ordering Physician
Physician Signature
Diagnosis Code(s)
Last Name
First Name
MI
Month
Day
Year
DOB:
/
/
Sex
Status
Date Drawn
Time Drawn
Nurse Initials
Standing Order (Maximum 3 month)
□
Fasting
Start Date
Frequency
End Date
M
F
□
/
/
/
/
Non-Fasting
/
/
ORDER SETS
TEST ALPHA LIST
Wellstone OBSTETRIC Order Set
ALT
IgA
T4, Total
- GR
- G or GR
- GR
CBC, Antibody Screen with reflex to ID and titer,
Amylase
IgG
Testosterone, Free
- GR
- G or GR
- G
ABO Group and Rh type, HBsAg w/ Rx Conf. ,
ANA
IgM
Testosterone, Total
- G
- G or GR
- G
Rubella Virus IgG antibody, RPR with Rx to Titer
Antibody Screen
Insulin
Total Iron Binding Capacity
- Pi
- G
-GR
& FTA-ABS
Wellstone COAGULOPATHY Work-up
AST
Iron
Triglycerides
- GR
- GR
- GR
PT/INR, PTT, Antithrombin [III] EZ Activity,
Beta hCG,serum, qualitative
LDH
TSH
- G
- GR
- GR
(Protein C Functional with Reflex to Protein C
Beta hCG,serum, quantitative
-
LDL Cholesterol
Uric Acid
G
- GR
- GR
Total Antigen + Protein S Free with Reflex to
Beta hCG,urine, qualitative
Lipase
Urinalysis
Protein S Total Antigen), Antiphospholipid
- G
- GR
- U
Syndrome Reflexive Panel, and Factor V Leiden
Urinalysis w/reflex to Cx
BNP
Lithium
- U
- Pu
- G
(F5) R506Q Mutation
BUN
Magnesium
Urine Dip Only
- GR
- GR
- U
Methylenetetrahydrofolate
Urine Drug Screen
Wellstone Iron Studies
Calcium
- U
- GR
Reductase 2muts (MTHFR)
- Pu
Valproic Acid, Total
CBC w/o Diff
- GR
TIBC, Ferritin, Fe, Transferrin
- Pu
QUAD SCREEN
CBC, Auto Diff
Platelet Count
Vit B12
- Pu
- Pu
- GR
EDD:
Creatinine
Potassium
Vit D, 1, 25-Dihydrox
- GR
- GR
-G
CRP-hs
Progesterone
Vit D, 25-Hydrox [def screen]
EDD Determined by:
- GR
- G
-G
Cyclic Citrullinated Peptide
Progesterone, 17 OH
URINE CHEMISTRY
Ethnicity:
(CCP)
- G
- G
Number of Fetuses:
Dehydroepiandrosterone Sulfate
Prolactin
12 Hr Urine Creatinine
- G
- G or GR
- TU
Maternal Weight:
Digoxin
Protein, Total
12 Hr Urine Protein
- GR
- GR
- TU
Protein C Functional w/reflex to
Insulin Dep. Diabetic:
Estradiol
24 Hr Urine Creatinine
- G
- TU
Prot C Total Antigen
- BL (S*)
History of Neural Tube Defect:
Factor V Leiden (F5) R506Q Mut
24 Hr Urine Protein
- Pu
- TU
Protein S, Free w/ reflex to Total
Previous pregnancy w/ Downs:
Factor X, Activity
Microalbumin
- BL (S*)
- U
Prot S Antigen
- BL (S*)
Donor Egg:
Ferritin
Random Urine Creatinine
- GR
- U
Folate, Serum [Folic Acid]
Prothrombin (F2) G20210A Gene
Random Urine Protein
Repeat Specimen:
-GR
- U
Mutation
- Pu
Acute Hepatitis
Follicle Stimulating Hormone
Wellstone
Order Set
CULTURES / MICROBIOLOGY
- G or GR
Hep A IgM,
ep B Surface Ag, Hep B Core IgM,
Genital, Chlamydia and
H
Fetal Bleed Screen
PSA, Free
- Pi
- G
Hep C Ab
Gonorrhea by DNA Probe -
GGT
PSA, Total
- GR
(Medicare Screening)
- G
Glucola 50 gm 1 Hour
PSA, Total
Ova and Parasites
- GR
(Non-Medicare Screen)
- G
- ST
Chronic Hepatitis
Glucose
PT/INR
Wellstone
Order Set
Rapid Strep
- GR
- BL
Hep B Surface Ag,
Hep A, total IgG and IgM,
Glucose 100 gm 3 Hr GTT
PTT
Stool Culture
- GR
- BL
Hep B Surface Antibody, Hep C Ab
Haptoglobin
Rheumatoid Factor
Throat Culture
- G or GR
- G
Hemoglobin / Hematocrit
Rh Typing
Urine Culture
- Pu
- Pi
Hemoglobin A1C
Ristocetin Co-Factor
PANELS
Urine, Chlamydia and Gonorrhea
- Pu
- BL (S*)
by Amplified Detec
Hepatitis A Virus Total Abs
Antiphospholipid Syndrome Rx Panel
(IgG & IgM)
- G
RPR with Rx to Titer, FTA-ABS
- G
(Beta-2 Glycoprotein 1 Antibodies --IgG & IgM,
Hepatitis A Virus Ab IgM
Routine Anerobic/ Aerobic
- G
Rubella IgG
- G
Cardiolipin Antibody --IgG & IgM, Lupus
Culture (Wound)
Hepatitis B Core Total Abs
(IgG & IgM)
- G
Sed Rate (ESR) -
Pu
Anticoagulant Reflexive Panel)
-
BL, G, (S*)
T3, Free
Hepatitis B Core Ab IgM
Other: Enter Source Below
- G
- GR
Basic Metabolic Panel
Hepatitis B Surface Ab
T4, Free
- GR
- G
- GR
Hepatitis B Surface Ag
COMMENTS:
- G
Comprehensive Panel
- GR
Electrolyte Panel
Hepatitis Be Virus Ab
- GR
- G
Hepatic Function Panel
Hepatitis Be Virus Ag
- GR
- G
Lipid Panel
- GR
Hepatitis C Virus Ab by CIA
- G
TEST ALPHA LIST
Hepatitis C RNA Quant by PCR
Specimen Collection Legend
- G
BL= Blue Sodium Citrate, G= Gold /Serum Separator, GR= Green Lithium Heparin,Pi=Pink
ABO/Rh
HIV 1/2 Ab w/reflex to Western Blot
- Pi
- G
EDTA, Pu=Purple EDTA, (S*)=Special Handling, U= Random Urine, UT=Urine Timed
Alkaline Phos
Homocysteine, Total Serum
- GR
- GR
Collection.
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