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Specimen Information

Date of Collection *

Time of Collection *

Collector Name*

Collected by *

Office StaffAdvanced Diagnostics

Type of Specimen

Blood SerumUrine
Whole BloodSputum
StoolPlasma

STAT Order?*

YesNo

Was the patient fasting*

YesNo

Icd10 codes

Add

Description *

Icd 10 gem codes	Icd 10 gem code description	Action

Please Select Insurance Type and add Primary Insurance Provider for Testing Options

Testing Option

PHYSICIAN SIGNATURE:

The ordering authorized Health Care Provider understands and hereby acknowledges that (a) the tests ordered are medically necessary for this particular patient, given the patient’s clinical condition, and have been recorded in the patient’s clinical file Read more

PATIENT SIGNATURE:

For non-touch screen devices, the patient needs to type their full name below, and provide a secondary identifier.

Add Signature

By selecting the Add Signature button, I attest that I approve of this digital signature

By my signature below I voluntarily consent to the collection and testing of my specimen and the release of the testing results to the ordering physician/facility, however such results shall be used solely for clinical diagnostic/treatment purposes only and shall not be used for any forensic purposes related to my Read more

PATIENT

PROVIDER

First Name:

First Name

Last Name:

Last Name

DOB:

DOB

Gender:

Gender

Address:

Address

Address 2:

Address2

City:

City

State:

State

Zip Code:

Zip Code

Phone No:

Phone No

Patient Ethnicity:

Patient Ethnicity

Weight (lbs.):

Weight (lbs.)

Height :

Height

Social Security Number:

Social Security Number

Is this a wellness patient :

Is this a wellness patient

Barcode:

Barcode

Please Provide Insurance Type :

Please Provide Insurance Type

Illness/Accident Date

Illness/Accident Date:

Accident Type :

Accident Type

Accident State

Accident State:

Bill to:

Bill to

Physician Name:

Physician Name

NPI:

NPI

Insurance Detail

COLLECTION DETAILS

DIAGNOSTIC CODES

Collected Date:

Date of Collection

Time Of Collection:

Time Of Collection

Collector Name:

Collector Name

Collected By:

Collected By

Specimen Type:

Stat Order?:

Was the patient fasting:

Was the patient fasting

Testing Options

Physician Signature / Date

Patient Signature / Date

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