Lab Test Request Form

Lab Test Request Form — Form Fields

This healthcare template includes 7 fields. Allows providers to submit and patients to request specific laboratory tests. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Birth (text, required)
• Ordering Provider Name (text, required)
• Tests requested (checkboxes, required) — options: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Lipid Panel, Hemoglobin A1c (HbA1c), Thyroid Stimulating Hormone (TSH), Urinalysis, Blood culture
• Clinical indication / reason for tests (long text, required)
• Is fasting required before the test? (multiple choice, required) — options: Yes, No, Unknown
• Preferred collection date (text, optional)