Requisition Form

Complete US BioTek Laboratories – Requisition Form

Interactive Requisition Form (All Tests) PDF – 553 KB

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 practitioner.
Check the appropriate box for billing. No other information is required when practitioner marks “bill practitioner”.

Credit Card Billing

Provide card number, expiration date, cardholder’s name, signature and amount in USD.
The above information can be omitted if practitioner has their credit card information on file with US Biotek Laboratories.

Please visit our FAQ page for any questions.