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RML FORM

REQUISTION FORM

17774 Preston Road, Dallas, TX 75252

Email :office@reliancemedlabs.com

CLIA#: 45D2099319

Phone #: (972) 925-0723

Fax#: (866) 230-5899

Please send patient’s demographics and copy of insurance card with requistion

Patient Information

Patient’s Last Name:

Patients First Name:

Patient’s Date of Birth:

Patient’s Social Security #:

Patient’s Address City, State, Zip Code:

Patient’s Phone Number:

Patient’s Email Address:

Patient’s Gender:

MALE FEMALE

Does Patient have insurance?

YES NO

Primary Insurance Provider:

Secondary Insurance Provider:

Member ID #:

Group ID #:

Member ID #:

Group ID #:

For Self Pay – Who do we contact for payment?

Contact name

Contact Phone Number

Physician and Facility Information:

Facility Name:

Authorizing Physician’s Name:

Facility Address, City, State, Zip Code:

Authorizing Physician’s NPI #:

Facility Phone Number:

Physician’s Phone Number:

Facility Fax Number:

Physician’s Fax Number:

Place a check mark by selected test and Ordering Physician should provide updated ICD10 codes that best describes the reason for the test

HEMATOLOGY

PCR TESTING

URINE TESTING

CBC H&H HbA1c ESR BNP

RP Panel – COVID+RSV+Influenza A/B RSV+Influenza A/B COVID+Influenza A/B COVID+RSV COVID Only RSV Only Influenza A/B Only

UTI Pathogens with Antibotic Resistance Urinalysis Uring Drug Screen Micro Albumin Micro Albumin/CR Ratio Culture, Urine

CHEMISTRY

IMMUNOASSEYS

CMP BMP CRP CK URIC ACID GGT Magniesium Phosphorus Iron PT/INR Lipid Profile Liver Function Renal Profile

Thryoid Panel w/ T3, T4, TSH Free T3 Free T4 Vitamin B12 Vitamin D-25 PTH Intact PTH w/ Calcium TIBC Folate Ferritin Wellness Panel – Female(CBC, CMP. HbA1c, Thryroid Panel w/ T3, T4, TSH,Vitamin B12,Vitamin D-25, UA, and UTI Pathogens withAntibotic Resistance) Wellness Panel – Male(CBC, CMP. HbA1c, Thryroid Panel w/ T3, T4, TSH, PSA,Vitamin B12,Vitamin D-25, UA, and UTI Pathogens with Antibotic Resistance)

OTHER TEST

Fasting (Circle One)

Yes No

Complete Questionnaire if Ordering a COVID Test

Are you employeed in Healthcare?

Yes No

Do you live in a congregate care setting (nursing home, group home, homeless shelter)?

Yes No

Are you you feeling Have come in contract with someone who has test positive with COVID-19 in the last 14 days??

Yes No

Are you you feeling poorly?

Yes No

If yes, what is the first date you strarted feeling poorly?

Yes No

Check any of the following symptoms:

Cough, Chills Diarrhea Fever Headache Loss of smell Loss of taste Nausea Shortness of breath

Please complete all form fields, incomplete requisition form will delay results

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