Forms andRequisitions

Please include a completed requisition with each patient sample referred to the Diagnostic Laboratories. You may print a blank requisition by selecting it below. Requisitions preprinted with your name, address and client number are available from Client Services.

Please note, if RNA or DNA samples are being sent, isolation of nucleic acids for clinical testing MUST occur in a CLIA-certified laboratory or a laboratory meeting equivalent requirements as determined by the CAP and/or the CMS. Additional specimen requirements can be found on the individual test requisitions or in our online test catalog.

• Hematology Genetics
• Hemostasis Testing
• Hemostasis Cryoprecipitate Quality Control Testing
• Hemostasis Frozen Plasma Quality Control Testing
• Histocompatibility Chimerism Testing
• Histocompatibility LOH Testing

• Histocompatibility Non-Transplant Testing
• Histocompatibility Transplant Testing
• IRL Prenatal Molecular Testing Requisition
• Immunohematology Requisition Form
• Platelet & Neutrophil Immunology Testing

• Informed Consent
• Medicare Beneficiary Form
• Patient Billing Form
• Patient Insurance Information Form-TRICARE

Additional Resources

• Single Gene CPT Codes

For IRL forms please visit the Immunohematology Reference Lab page.

To request Platelet Aggregation testing for your patient, complete this form. Testing available for Wisconsin-based clients only.

For additional information review the provider and patient information sheets.

• Patient Information for Platelet Aggregation Testing
• Information for Providers - Platelet Aggregation Testing