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CONSTITUTIONAL (BLOOD) TEST REQUISITION FORM - genetics medicine iu 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling out the 'Physician(s)' section. Enter the ordering physician's name, address, and contact information. Ensure you provide a signature for authorization.
- Next, complete the 'Patient Information' section. Input the patient's full name, address, date of birth, and sex. Indicate if the patient has recently been pregnant.
- In the 'Clinical Information' section, specify the collection date and time. Select whether the sample is blood or cord blood and include who collected it.
- Proceed to 'Referring Diagnoses' and check all applicable diagnoses that pertain to the patient’s condition.
- Fill out the 'Requested Testing' section by selecting appropriate tests based on clinical needs. Ensure you note any specific requirements for specimen collection.
- Complete the 'Patient Financial Authorization/Insurance Benefit Verification' section carefully, ensuring all signatures are obtained where necessary.
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