Healthcare CBC BMP UA

Healthcare CBC BMP UA

Patient Information

Date of Birth:    Gender:    Phone:

Insurance & Billing

Policy Number:    Group Number:

Medical History

Pregnant or nursing?    Taking anticoagulants or blood thinners?

Ordering Provider

Provider NPI:    Clinic / Facility:

Provider Phone:

Requested Tests

CBC (Complete Blood Count)    with differential

BMP (Basic Metabolic Panel)

UA Dipstick    UA Microscopic    UA Culture

Specimen Collection

Specimen Type:

Date Collected:    Time Collected:    Collected By:

Fasting? (If required for tests)    Last oral intake at:

Special handling (check all that apply): Ice    Refrigerate    Protect from light

Authorization and Consent

I authorize the collection of specimens and performance of laboratory testing requested above. I understand that common risks associated with venipuncture include bruising, hematoma, infection, fainting, and pain at the collection site. I acknowledge that the benefits include diagnostic information to aid in my medical care. I have had the opportunity to ask questions and those questions were answered to my satisfaction.

I authorize release of the test results to the ordering provider, appropriate healthcare personnel, and entities involved in my care. I understand that retained specimens may be used for additional testing or quality assurance and that personally identifiable information will be protected in accordance with privacy policies. I may revoke this authorization in writing, except to the extent that action has already been taken in reliance on it. This authorization expires on the date indicated below or upon completion of the requested testing, whichever occurs later.

By signing below I acknowledge that I have read and understand this consent and authorize the tests ordered above.

Patient acknowledges receipt of privacy practices and laboratory testing information:

Sign Now