Sample Test Requisitions

To request printed test requisitions, please go to “contact and support” and use the client supply request form on this website.  You must be a registered provider to receive Litholink’s Test Request Form (TRF).

Test Requisition Instructions

Complete all required fields on test requisitions. Ensure that all required fields are filled out and the information submitted is accurate.

Provider: Name, address, ordering physician, phone #, physician/authorized signature
Patient: Name, gender, DOB, Shipping address for faxed orders
Clinical: ICD-10-CM,
Tests/Panel: Select tests to be performed

Samples of Test Request Forms (PDFs) may be viewed and downloaded here. If necessary, download Adobe Acrobat Reader.