About this template
A laboratory requisition form is an essential tool used by medical clinics, healthcare providers, and researchers to formally order diagnostic tests and communicate patient sample requirements to testing facilities. By centralizing patient details, clinical notes, and specific test panels into a single document, clinics reduce administrative errors and accelerate turnaround times for patient results.
This ready-to-use template captures essential demographic details, specific diagnostic tests requested, clinical indications, and billing information in an organized layout. Medical staff can easily deploy this form digitally, allowing physicians or intake coordinators to submit complete test orders instantly from any device.
Built for seamless integration with Google Workspace, Doc2Form enables healthcare teams to turn static workflows into dynamic digital intake forms. Whether you operate a private medical practice, a specialized clinic, or a research lab, this template ensures accurate, secure, and rapid transmission of laboratory orders.
Key features
- Standardize test ordering across physicians and departments.
- Capture complete patient demographics and insurance data accurately.
- Specify exact panels, procedures, and special handling instructions.
- Instant data storage in Google Sheets for real-time order tracking.
Use cases
- Outpatient medical clinic diagnostic ordering
- Specialty laboratory sample drop-off requests
- Routine annual wellness bloodwork requisitions
- Clinical research participant testing schedules
What this form collects
- Patient Full Name (Short answer)Enter the patient's first, middle, and last name as shown on their insurance card.
- Date of Birth (Date)Select the patient's date of birth.
- Biological Sex (Multiple choice)Select the patient's biological sex for reference range calculations.
- Contact Number (Short answer)Provide the patient's primary phone number for result notifications or urgent queries.
- Email Address (Short answer)Enter the patient or ordering provider's email address.
- Patient Residential Address (Paragraph)Enter the complete street address, city, state, and ZIP code.
- Ordering Physician Name (Short answer)Enter the name of the licensed practitioner requesting these tests.
- Clinical Diagnosis / ICD-10 Code (Paragraph)Provide the primary diagnosis or symptoms justifying the test order.
- Tests and Procedures Requested (Checkboxes)Select all laboratory panels or diagnostic procedures required.
- Specimen Collection Date (Date)Enter the date the sample was or will be collected.
- Fasting Status (Multiple choice)Was the patient fasting at the time of specimen collection?
- Additional Instructions or Clinical Notes (Paragraph)Include any special handling instructions, STAT priority notes, or relevant clinical history.
FAQ
Why is a laboratory requisition form template necessary?
It standardizes the test-ordering process between healthcare providers and testing laboratories, ensuring all necessary clinical information, billing data, and patient identifiers are provided accurately to avoid testing delays.
Can I customize the list of available lab tests on the form?
Yes. Once you import this template into your Google Forms account, you can fully edit, add, or remove test options to match the specific services your clinic or lab offers.
How do patients or physicians submit this form?
You can share the Google Form via a direct link, embed it on your secure clinical portal, or have intake staff fill it out during patient check-in.
Where are the submitted lab orders stored?
All responses are automatically routed to a linked Google Sheet, giving your administrative team a real-time, searchable database of all active lab requests.
How do I get started with this template?
Simply use Doc2Form to instantly generate this template in your Google Forms account, customize the fields to your workflow, and start collecting submissions immediately.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.