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Click ‘Get Form’ to open it in the editor.
Begin by entering the patient’s first and last names in the designated fields. Ensure that these names match exactly with those on the specimen container.
Complete the submitter information section, including the name of the authorized person requesting the test.
Indicate the patient’s race, ethnicity, and sex in their respective fields.
If applicable, fill in the outbreak number field to provide context for the test request.
Record the date when the specimen was collected in the appropriate field.
Specify the specimen source next to the Influenza (Types A & B) Test requested using only the provided codes.
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Parents or guardians must submit a Maryland Department of Health and Mental Hygiene (DHMH) Blood Lead Testing Certificate, which is available from the school or
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