Free template · PDF
Lab request form template
A request the laboratory can process without a phone call: the sample, the tests and the clinical question on one page.
Download the PDFFree, no sign-up. Fill it in on screen or print it.
What is on the form
- Practice details, date, laboratory and request number
- Patient: name, date of birth, MRN and address
- Sample: taken, by, type and fasting status
- Tests to tick, from full blood count and renal and liver profiles to HbA1c, thyroid function, vitamin D and CRP
- Routine or urgent, GMS-eligible or private
- Clinical details
- A note for the patient
- Sign-off: name, qualifications and Irish Medical Council number
Using it well
- Check the tick-list against your laboratory's own request requirements before first use.
- Clinical details help the lab: say what you are looking for.
Less paperwork to fill in at all.
Ask Brigid keeps the diary, the record and the practice paperwork in one place, hosted in AWS Dublin. Practice management for private consultants.
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