The Printable Lab Requisition Form Template – Canada is offered in a variety of formats, including PDF, Word, and Google Docs. These formats are both customizable and print-friendly, ensuring they cater to your specific requirements effortlessly.
Printable Lab Requisition Form Template – Canada Editable – PrintableSample
1. Patient Information 2. Referring Physician Information 3. Laboratory Tests Required 4. Clinical Information 5. Additional Instructions 6. Consent for Testing 7. Signature of Referring Physician 8. Lab Usage Declaration 9. Contact for Results
PDF
WORD
Examples
Name: [Patient’s Name]
Date of Birth: [DD/MM/YYYY]
Health Card Number: [Health Card Number]
Address: [Patient’s Address]
Phone: [Patient’s Phone]
Email: [Patient’s Email]
Name: [Physician’s Name]
Clinic Name: [Clinic Name]
Address: [Clinic Address]
Phone: [Clinic Phone]
Fax: [Clinic Fax]
Email: [Clinic Email]
1. [Test Name 1] – [Indication/Comments]
2. [Test Name 2] – [Indication/Comments]
3. [Test Name 3] – [Indication/Comments]
Please provide relevant medical history and any previous test results that may assist in the diagnostics.
[Physician’s Signature]
[Date of Signature]
Name: [Patient’s Name]
Date of Birth: [DD/MM/YYYY]
Health Card Number: [Health Card Number]
Address: [Patient’s Address]
Phone: [Patient’s Phone]
Email: [Patient’s Email]
Name: [Physician’s Name]
Clinic Name: [Clinic Name]
Address: [Clinic Address]
Phone: [Clinic Phone]
Fax: [Clinic Fax]
Email: [Clinic Email]
1. [Test Name 1] – [Indication/Comments]
2. [Test Name 2] – [Indication/Comments]
3. [Test Name 3] – [Indication/Comments]
Ensure all details are filled accurately to avoid delays or miscommunication with the lab.
[Physician’s Signature]
[Date of Signature]
Printable
