Infectious Disease Serology Test Request Form
Patient Name
Patient ID
Date of Birth
Sex
Male
Female
Other
Requesting Physician
Date Requested
Phone
Email
Clinical Information / Notes
Serology Tests Requested
HIV
Hepatitis B
Hepatitis C
Syphilis (VDRL/RPR/TPHA)
Dengue
CMV
EBV
Rubella
Toxoplasma
Measles
COVID-19
Other
Other Instructions
Physician Signature
Date Signed