TEST REQUISITION FORM Cytogenetic Laboratories - IU Health 2026

1. Click ‘Get Form’ to open the TEST REQUISITION FORM in the editor.
2. 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.
3. 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.
4. In the CLINICAL INFORMATION section, specify the collection date and time. Select whether it is blood or cord blood and indicate if the patient has been recently transfused.
5. Check all applicable REFERRING DIAGNOSES from the list provided. This helps in identifying relevant medical conditions.
6. For REQUESTED TESTING, select the appropriate tests required based on your clinical needs. Ensure you understand each test's requirements regarding specimen collection.
7. Complete any necessary financial authorization details to facilitate insurance billing and verification.

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