Soldotna: (907) 714-4418 Fax (907) 714-4971

250 Hospital Place, Soldotna, AK 99669

Kenai: (907) 714-4495 Fax (907) 283-0794
(907) 714-4404 * www.cpgh.org
LABORATORY REQUISITION
Patient Name (Last, First, MI) Date Collected:
Test Requested By: (Practitioner Signature)
Birth Date (Required) Age Sex Marital Status Telephone #:
Ordering Physician (please print)
Address Diagnosis/Symptom and/or ICD10 Codes: (Required)
City State Zip

Routine Urgent Fax Results

(IF SENDING SPECIMEN ONLY, MUST COMPLETE THE FOLLOWING)
HEALTH PLAN INFORMATION:
Medicare #: Medicaid #: Private Insurance (Please attach information)
MEDICARE MAY DENY PAYMENT FOR THOSE TESTS MARKED WITH AN *
Hepatitis*

CHEMISTRY SEROLOGY URINALYSIS

FOR SINGLE CHEMISTRIES
Lipid *

X Ammonia MONO UA (dipstick only)*

Lytes
Liver
CMP
BMP

MARK EACH TEST

Amylase Rheumatoid Factor UAO (microscopic if indicated)*
PANELS CRP (non cardiac) RSV UAC (culture if indicated) *
Sodium GGT * Strep Screen Urine microscopic*
Potassium Glucose 1 hr Challenge* ANEMIA Urine Culture and Sensitivity*
Chloride Glucose 2 hour PP * B12 SEMEN ANALYSIS
Total C02 Glucose Tolerance * Ferritin * Contact Lab for Scheduling
Calcium hours Folate Post Vasectomy
Glucose * Glycohemoglobin * Iron * Semen Analysis
BUN Lactic Acid Iron Binding Capacity * HEMATOLOGY
Creatinine LDH Transferrin * CBC (Diff & Platelets*)
Total Protein Lipase THERAPEUTIC DRUGS Hemaglobin *
Alk. Phos Magnesium* Date/Time of last dose: Hematocrit *
Albumin Osmolality Platelet count *
AST (SGOT) Phosphorus Carbamazepine (Tegretol) Reticulocytes *
ALT (SGPT) Prealburnin Digoxin * Sed Rate (ESR)*
Bilirubin Total Uric Acid Gentamycin HEMOSTASIS
Bilirubin Conjugated Vitamin D * Lithium Anticoagulant:
Bilirubin Neonatal ENDOCRINOLOGY Phenobarbital Dimer - DIC
Cholesterol * Cortisol Phenytoin (Dilantin) Dimer - PE
Triglyceride * FSH Tobramycin Fibrinogen
HDL * HCG Qualitative Valproic Acid (Depakote) Protime (& INR) *
INFECTIOUS DISEASE HCG Quantitative Vancomycin PTT *
HEP B Surface Ab Total LH URINE CHEMISTRY MICROBIOLOGY
HEP B Surface Ag * Progesterone Random 24 Hour Source:
HEP B Core Ab IgM * PTH-Intact Creatinine Clearance
HEP C Ab * TSH * Ht: Wt. Antibiotics:
HEP A Ab IgM * TSH Reflex to T4 * done Ketones
HIV * T4 Total * Lytes AFB Culture/Smear
Mumps IgG T4 Free * Microalbumin Anaerobic Culture
Rubella IgG T3 Total * Osmolality Blood Culture
Rubeola IgG T3 Free * Protein C- difficile Toxin
Vancella Zoster Ab IgG CANCER MARKERS BLOOD BANKING Culture with Sensitivity
CARDIAC CA 125 * ABO type & RH Fecal Lactoferrin
CK CA 19-9 * Cross Match Fungal Culture
CRP High sens. CA 15-3 * # of Units GC/Chlamydia PCR
NT - proBNP* CEA * Direct Coombs GI Panel PCR
Troponin PSA - Total * Rhogam Ante Post Influenza A/B PCR
MISC TESTS MRSA Culture
Occult Blood *
Ova & Parasites
Respiratory Panel PCR
Strep Group B
TB Screen PCR
Throat Screen (Gr. A Strep)
Viral Culture
LABOO2 SO/2PT/PMR, Rev 07/16