+
Add logo
Lab & Diagnostics Request Form
Laboratory & diagnostic imaging request
01
Patient
Patient name
Species
Breed
Age / DOB
Sex / neuter status
Weight
kg / lb
Patient ID
Requesting veterinarian
Date
Time
02
Clinical history
Clinical question / reason for testing
Current medications
Relevant history
03
Sample
Whole blood (EDTA)
Serum
Plasma
Urine
Feces
Fine needle aspirate
Tissue / biopsy
Swab
Fluid
Hair / skin
Collected at (time)
Site / method
Fasted?
Stored
04
Tests requested
Blood & urine
CBC
Chemistry panel
Electrolytes
Total T4
SDMA
Bile acids
Coagulation panel
Blood type / crossmatch
Urinalysis
Urine culture
Urine protein:creatinine
Blood gas
Other diagnostics
Cytology
Histopathology
Fecal flotation
Heartworm test
FeLV / FIV
Tick-borne panel
Culture & sensitivity
Cortisol test
Radiographs
Ultrasound
ECG
Blood pressure
Other tests, views, or regions
05
Tracking
In-house / lab
Accession #
Sent on
Results received
Reviewed by