HTML Preview Lab Requisition Form page number 1.
MemorialCare Medical Group provides professional services exclusively on behalf of MemorialCare Medical Foundation Rev.10/11
LAB REQUISITION FORM
PATIENT TO HAND CARRY THIS FORM TO ANY MCMG LOCATION LISTED BELOW
Call office to obtain lab hours, as they vary per location
15 Mareblu, Suite 100, Aliso Viejo, CA 92656 • (949) 448-0656
3010 W. Orange Avenue, Suite 302, Anaheim, CA 92804 • (714) 826-1200
722 Baker Street, Costa Mesa, CA 92626 • (714) 557-6300
11420 Warner Avenue, Fountain Valley, CA 92708 • (714) 549-1300
250 E. Yale Loop, Suite 200, Irvine, CA 92604 • (949) 551-1090
26991 Crown Valley Parkway, Mission Viejo, CA 92691 • (949) 582-2002
23512 Madero Rd., Mission Viejo, CA 92691 • (949) 583-1600
29472 Avenida De Las Banderas, Rancho Santa Marg, CA 92688 • (949) 459-9968
30300 Rancho Viejo Road, San Juan Capistrano, CA 92675 • (949) 661-9600
1212 W. 17
th
Street, Santa Ana, CA 92706 • (714) 954-0432
**THIS FORM IS NOT TO BE USED FOR PRE-OP ORDERS**
Amylase FSH Ova & Parasites PSA Free, Total
ANA Genital Beta Grp B Panel , BMP PT/INR
Billiru/TD/Neonatal Glucose Fasting Panel, CMP PTT
B12 and Folate GTT 1 hr Panel, CMP w/GFR RA Factor
CBC/Diff GTT 3 hr (Requires Appt) Panel Hepatitis Resp. Region 13
CEA H. Pylori UBIT Panel, Lipid RPR
Child Food/Envirn Hep A Ab Panel, Liver Rubella
Chlam + GC Amp. Hep B Ab Panel, Lymph Sed Rate
Chlamydia Amp. Hep B surf Ag Panel Thyroid/TSH Tacrolimus
Creat. clearance Hep C Ab Phenytoin Testost, total
Culture, Aerobic HGBA1c Phosphorus Throat-Strep A Cult
Culture Herpes Simp HIV Ab Preg, HCG Qual TSH
Culture Stool Iron IBC Preg, HCG Quan TSH/Reflex to FT4
Culture Throat Lead Prenatal Panel T4 Free
Culture Urine LH Progesterone Uric Acid
Cyclosporin Lipase Prolactin Urinalysis
Ferritin Magnesium Protein 24 hr urine Urine micro on pos
Food Allergy Microalbumin PSA
Other Tests:
Patient Name: ________________________________________ DOB: _____________________________
MCMG Primary Care Physician: ___________________________________________________________
Diagnosis: ________________________________ ICD-9 Code (REQUIRED): _____________________
Referring Provider: ____________________________________ Phone: ___________________________
CC: Results to: Quest Acct #
(Care360 users): ________________ or Fax # (non-Care360 users):____________
Signature: ____________________________________________ Date: _____________________________