Providers Referring providers, submit a request for lab work by completing the form below. Provider InformationProvider Name* First Last NPI* Phone*Fax*Diagnosis Code(s)* Is this a STAT order?* Yes No Labs Requested* Hemoglobin A1c Albumin PSA Lipid Panel Alkaline Phosphatase PSA, Free: Total Ratio PT/INP ALT (SGPT) PT and PTT Activated Glucose Amylase PTT Activated Hemoglobin Antinuclear Antibodies RPR Urinalysis AST (SGOT) Rubella Antibodies, IgG Urine Drug Screen B12 and Folate Sed Rate, Westergen Urine Preg Test Bilirubin, Total Sodium Microalbumin Creatinine BUN Testosterone, Total H. Pylori Whole Blood Calcium Thyroid Cascade Profile Covid-19 C-Reactive Protein Quant Thyroxine (T4) Acute Hepatitis Panel hs Cardiac C-Reactive Protein Thyroxine (T4), Free Basic Metabolic Panel CEA Triglycerides Comp Metabolic Panel Creatinine Triiodothyronine (T3) Electrolyte Panel Ferritin T3 Uptake Hepatic Function Panel FSH and LH TSH, 3rd Generation Kidney Profile GGT Uric Acid Lipid Cascade Hep A Antibody, IgM Vitamin D, 25-Hydroxy Renal Function Panel Hep B Surface Antibody Urine Culture Routine CBC w Diff w Pit Hep B Surface Antigen Additional Test CBC w/o Diff w Pit HIV-1/0/2, 4th Generation Hematocrit Iron and IBC Platelet Count Magnesium RBC Count Phenytoin (Dilantin) WBC Count BUN Lipid Panel w/LDL/ Lipid Panel w/NON-HDL HDL Ratio Cholesterol Patient InformationPatient Name* First Last Date of Birth* MM slash DD slash YYYY Patient Phone*Patient Email Patient Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Insurance Company* If you are uninsured type None in the field. Group* ID/Policy*