Toxicology Screening Laboratory Request Form
Patient Information
Patient Name
ID Number
Date of Birth
Gender
Male
Female
Other
Request Details
Date of Request
Requesting Physician
Department / Ward
Specimen Details
Type of Specimen
Urine
Blood
Other
Date & Time Collected
Requested Screening Panels
Amphetamines
Barbiturates
Benzodiazepines
Cannabinoids (THC)
Cocaine
Opiates
Other (Specify Below)
Other tests / Additional Information
Authorization
Physician Signature
Date