Healthcare CBC Form

HEALTHCARE CBC FORM

Patient Information

Date of Birth:    Gender:    Phone:

Insurance Information

Policy Number:    Group Number:    Subscriber Name:

Clinical / Medical History

Tests Requested

Select tests to be performed CBC with differential
CBC (no differential)
Hemoglobin / Hematocrit
Platelet count
WBC with differential (manual review if indicated)
Peripheral smear examination
Reticulocyte count
Other:

Specimen Collection

Specimen Type: Venous Capillary (fingerstick) Other:

Collection Date:    Collection Time:    Collected By:

Fasting Status:

Priority: Routine STAT

Clinical Indication

Ordering Clinician

Clinic / Facility:    Phone:    NPI / Provider ID:

Patient Consent and Authorization

I, , authorize the collection of blood for the laboratory tests indicated above. I understand that venipuncture or capillary collection may cause pain, bruising, infection, fainting, or other complications. I have had an opportunity to ask questions and my questions have been answered to my satisfaction.

I authorize the laboratory to release results to the ordering clinician and to the facility identified above. I understand that specimens may be retained for quality control and that testing may be performed by the ordering facility or by a reference laboratory as required for clinical care.

Authorization Expiration Date: . I understand I may revoke this authorization in writing, but revocation will not affect actions already taken based on this authorization.

HIPAA Privacy Acknowledgement: I acknowledge I have been offered or received the facility's privacy practices notice and that my health information related to this test may be disclosed to the ordering provider and other persons involved in my care as permitted by law.

Lab Use Only

Accession Number:    Specimen ID:

Received Date:    Received Time:    Initials:

Specimen Acceptance Notes: Specimens that are clotted, hemolyzed, or insufficient in volume may be rejected or the test results canceled. Additional tests may be reflexed per laboratory policy based on preliminary findings and clinical indication.

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