R&S United Health Services Online Lab Request Form
Head Office: 917 Beville Road, Suite B, South Daytona Beach, FL 32114 Email: info@rsunitedhealthlab.com | Phone: 386-562-1052 | Fax: 888-919-5502
Note
Please fill out the form below, sign and click "SUBMIT" at the bottom. *Incomplete or inaccurate information may delay order*
PATIENT INFO
Patient first Name
Patient Last Name
Patient D.O.B.
Age
Sex
Male
Female
Patient Phone Number
Patient Address
INSURANCE INFO
Insurance Name
ID Number
Group #
PHYSICIAN INFORMATION
Ordering Physician
70
NPI or UPIN #
Physician's Contact Number
Facility
Fax Number
Ordering Physician Email
Physician Address
Send additional copy of report to
REQUESTED TEST INFORMATION
Specimen
Blood
Urine
Stool
Swab
Request date
Diagnosis Code
STAT?
YES
NO
Fasting
Yes
No
Collection Date
Hospital Patient Status
In-Patient
Out-Patient
Non-Patient
CHEMISTRY TEST REQUEST
GTT 3Hrs
GGT 5 Hrs
Glucose-FBS
Glucose Random
Glucose 2 Hr. PP
HBA1C (Glyco Hb)
BUN
Creatinine
Electrolyte (Na,K,CL,CO2)
Uric Acid
Protein Alb/Glob
Protein Electrophoresis
Bilirubin
Alk Phos.
SGOT
SGPT
GGTP
Magnesium
LDH
CK-MB
CPK
Troponin 1
LIPID (Chol, Trig, HDL,LDL)
Triglyceride
HDL - Chol
LDL - Chol
Lipoproteins
Calcium
Phosphorous
PSA Total
PSA Free/Ratio
Amylase
SPECIAL CHEMISTRY (Drug test)
Alcohol
Cocain
Marijuana
Heroin
Amphetamine
Lithium
Lead
FECES
Amoeba
OVA/Cysts
Parasite
Occult Blood
SEROLOGY TEST
ASTO
CRP
R A Latex
VDRL
FTA - TPHA
Herpes ½ IgG
Herpes ½ IgM
HS CRP
ENDOCRINOLOGY
Beta HCG (Qual)
Beta HCG (Quan)
Estradiol
PTH
FSH
TSH
Progesterone
Testosterone.
Testosterone Free
T3 Total.
T3 Free
T4
T4. Free. Uptake
LH
Prolactin
Growth Horm.
BACKTERIOLOGY TEST
Culture & Sens-Swab/Stool
Culture & Sens - Urine
Herpes Culture
H.Pylori Ab
H.Pylori Ag
Gram Smear
HEMATOLOGY TESTS
HB/PCV/MCHC
RBC
MCV
CBC
WBC
ESR
Platelets
Sickle
Genotype
Retic
Group and RH
Ferritin
Iron and TIBC
Folic Acid
Vitamin B12
PT
PTT
INR
Indirect Coombs
Direct Coombs
D-Dimer
Clotting Time
Thrombin Time
Malaria Parasites
URINE
Pregnancy
Urinalysis - Comp
Cortisol AM
Cortisol PM
Micro albumin
Amylase
Sodium
Creat. Clearance
Protein 24hr
Calcium
Phos.
Potassium
Chloride
IMMUNOLOGY
ANA
Choice 2
ds DNA
ANA Profile
HBsAG
HBsAb
HBcAB
Hep A
Hep C
CEA
CA 125
CA 15-3
B2 Microalbumin
Alpha Fetoprotein
CD4
CD8
CD3
HIV 1 / 2
HTLV 1 / 2
Rubella Ab IgG
Rubella Ab IgM
Dengue Ag
Dengue AB IgG/IGM
Chlamydia Ag
C3 Complement
C4 Complement
Viral Load
PROFILE
ANTENATAL 1: Hb, Gp, RH,VDRL,Sickle,HIV
ANTENATAL 2: Hb, Gp, RH,VDRL,Sickle,Rubella,HIV
ANTENATAL 3: +HBSaG
ARTHRITIC 1: Uric Acid, Ra, CRP, ASTO, ESR
ARTHRITIC 2: +ANA
ANA Profile: SM, RMS, Ro/SS-A, La/SSB,Antibody. TORCH: Toxo,Rubella,CMV,Herpes
EXECUTIVE: FBS, Uric Acid,Protein Alb/Glob,Chol,BUN,Bilirubin,SGOT,Trig,HDL,Creat,Alk Phos, Calc
HYPERTENSION: CBC,FBS,Lipid,BUN,Creat,Electro,Uric Acid,Urinalysis
ABO and Rh: ABO Blood grouping, RH typing
B12 and FOLATE: Vitamine B12, Folate (Folic Acid)
FSH and LH: FSH, LH
ELECTROLYTE PANNEL: Chloride, CO2, Potassium, Sodium
GENITAL MYCOPLASMA: mycoplasma Genitalium, mycoplasma hominis, Ureaplasma spp
Ct/Ng/Tv: Chlamydia trachomatis NAA, Neisseria gonorrhoeae NAA, Trichomonas Vaginalis NAA
H PYLORI UREA BREATH: Pre-ingestion (Blue bag), Post-ingestion (Pink bag), Pranactin breath (Adult
THYROID PROFILE: T3 Free, Thyroxine free Direct, Thyroid Peroxidase (TPO) Ab
LIPID CASCADE: Chol Total, Triglycerides, HDL Chol, LDL Chol calc, LDL/HDL Ratio, non-HDL Chol calc
+ lipoprotein analysis by NMR
MISCELLANEOUS TESTS
Paternity Test - DNA
Pap Smear
Semen analysis
Chlamydia/Gonorrhea
STI Quad Panel
STI 9
Stone Analysis
OTHER TEST
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Ordering Physician Signature
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