US BioTek Laboratories - Requisition Form
Interactive Requisition Form (All Tests) PDF - 553 KB (file needs to be saved locally before use)
How to Complete Test Requisition Form
Print patient's name legibly, last name first.
Print patient's address, age, sex, date of birth and day and evening phone numbers.
Record specimen collection date, collection time, date specimen is sent, and storage conditions if the specimen is not mailed immediately after collection (i.e. ambient temperature, frozen, refrigerated).
Clearly mark the requested test panel(s).
Requisition form must be signed by the ordering physician.
Check the appropriate box for billing. No other information is required when physician/ practitioner marks “bill physician”.
Credit Card Billing
Provide card number, expiration date, cardholder's name, signature and amount in USD.
The above information can be omitted if physician/practitioner has their credit card information on file with US Biotek Laboratories.