Lab Test Add on Form
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Laboratory Client Notices
School of Medical Laboratory Science
PRACTICE NAME:
ADDRESS:
CITY:
STATE:
ZIP CODE:
CLIENT NUMBER:
SENT BY:
PHONE NUMBER:
EMAIL:
DATE OF SERVICE THIS TEST IS BEING ADDED TO:
REQUISITION NUMBER:
Please add the test(s) listed below to the specimen previously sent on the following patient
PATIENT'S FIRST NAME:
PATIENT'S LAST NAME:
PATIENT'S DATE OF BIRTH:
ADD ON TEST #1:
DX CODE #1:
ADD ON TEST #2:
DX CODE #2:
ADD ON TEST #3:
DX CODE #3:
ADD ON TEST #4:
DX CODE #4:
ADD ON TEST #5:
DX CODE #5:
ORDERING PHYSICIAN(S):
