Requisition Information

Specimen and Patient Referral 

Test samples can be referred to Nationwide Children's Laboratory Services or patients can be sent our Laboratory Service Centers for sample collection and submission.

Patient Referrals for Collections

Patients referred to any of our Laboratory Service Centers should proceed to registration and present the written physician order for laboratory testing. A lab or ChildLinkTM test requisition should be used, or a physician script may be used.  Any Cytogenetics requests must use the Cytogenetics requisition and a Cystic Fibrosis consent form must accompany this requisition if a CF screen is to be performed. Please contact Laboratory Services for specific information: (614) 722-5477 or (800) 934-6575.

The physician script must provide the following information:

  • Ordering physician’s full name, address, phone number, and physician signature

  • Patient’s name and date of birth

  • Tests requested

  • Diagnosis and/or ICD-9 Codes

  • Date and time of order

  • Additional information

Other necessary information relevant to testing will be obtained by laboratory personnel

NOTE: Please indicate on the requisition or physician script if the parent, guardian or patient is authorized to receive results. Also, provide special information for calling results, handling the specimen, or other factors which might affect testing or interpretation of results. For example, dosage information for drug testing or hours fasting for a Fasting Lipid Profile test.


Laboratory Services will provide a test requisition to clients for specimen referral and patient referral.

The test requisition combines patient registration information, billing information, specimen information, barcoded specimen labels and a physician order for confirmation of testing. The patient bill requisition should be completed by the physician or authorized staff and signed by the ordering physician.  

Please assure accuracy of all patient information. Questions or concerns regarding completion of requisitions can be directed to Laboratory Services at (614) 722-5477 or (800) 934-6575.  

Test Requisitions

View a sample Test Requisition.

All areas listed below are required fields.

Area 1: Patient Information

Print patient’s full last name, first name and middle initial, date of birth, sex, race, social security number, address, and phone number.

Area 2: Billing Information (When Billing the Patient’s Insurance)

Print Custodial/ Parent’s last name, first name and middle initial, the subscriber’s last and first name and their date of birth, relationship to patient, subscriber’s social security number, insurance policy and group number, employer, and insurance company’s name and address.  Also, if the patient has a secondary insurance, please list.  NOTE: It is vital that the billing information be accurate so that the insurance carrier is billed and not the patient.  If you prefer you may attach a photocopy of the patient’s insurance card to the requisition to insure proper billing.

Area 3: Specimen Information

Print the date and time the specimen was collected, the collector’s full name, first and last, and the temperature at which the specimen was held before it was received in the lab.

Area 4: Test Selection

Mark an “X” in the appropriate boxes for requested testing. Custom test(s) is an area reserved for frequently ordered tests by a physician. If a test does not appear on the list it can be hand printed in the section labeled Other Test(s).  

Area 5: Diagnosis/ICD-10, Physician signature

Print the Diagnosis/ICD-10 codes. This information is needed for registration, documentation of medical necessity and billing purposes. The physician or authorized staff must then print his/her name and then sign and date in order to confirm the order for laboratory testing.

Area 6: Barcode specimen labels

Use the barcode labels to attach to the patient’s specimen and include the patient’s full name on the label as well.

Additional Requisition Information

For the Genetic Test Requisition Form click here.

For the Oncology Genetic Requisition Form, click here.

For Anatomic Pathology Consult Requisition Form, click here.