Instructions for Completing ITxM Diagnostics Test Requisition Form

1. Complete a separate Test Requisition for each patient.
2. Please use a pen to complete the form. Be sure to PRINT legibly.
3. Record the Following
   • Your client account number or hospital name/address if not already there.
   • Patient name, patient ID (not SSN), date of birth, sex, lab ID number
   • Collection date/time
   • Ordering physician name
4. Complete medication history area (if applicable). It is especially important to note any COUMADIN, HEPARIN, or direct thrombin inhibitors (such as Lepirudin or Argatroban) in use.
5. Mark box(es) with an x or Ö indicating the tests requested. If you wish to decline automatic reflexing of a test, you must mark the box provided for this purpose.
6. If requesting the Heparin Level/anti Xa Assay, mark the type of heparin the patient is receiving. This information MUST be provided; otherwise the laboratory will run the assay as if the patient is receiving unfractionated heparin.
7. Write the required patient information on the specimen container. Refer to Specimen Labeling Policy.
8. Keep the bottom copy of the requisition for your records. (if downloading the requisition from this website, please make a copy for your records.)
9. Fold the remaining copy of the requisition with the patient information facing out.
10. Place the labeled specimen(s) in the ziplock portion of the specimen bag. Place the folded test requisition into the outside pocket of the specimen bag.
11. If multiple transport temperatures are required, place specimen(s) in separate bags. Refer to the Shipping/Packing Instructions.