Lab Request Form Skilled Nursing Facilities

Skilled Nursing Facilities (SNF):

Please provide the following information to request SNF services:

Facility No.

Facility Name.

Address

Address Line 1

Address Line 2

City

State

Zip Code

Contact Name

Contact Phone

Which nursing station(s)?

Date of Service

Number of Patients to be Drawn

Patient Name #1

Patient Name #2

Patient Name #3

Patient Name #4

Patient Name #5

Please check all of the following boxes that apply to this request

There is at least one Stat draw

There is at least one Routine draw

There is at least one Fasting patient

There is at least one Standing Order draw

There is at least one Specimen Pickup

Are any of these patients time draw?

If yes, please list the time(s)

Special Remarks