Occupational Health Lab Test Request Form
Employee Information
Full Name
Employee ID
Date of Birth
Department
Contact Information
Email
Phone
Lab Tests Requested
CBC (Complete Blood Count)
Urinalysis
Blood Glucose
Lipid Profile
Liver Function Test
Drug Screening
Other
If Other, please specify
Reason for Test
Reason
Pre-employment
Routine Monitoring
Post-Exposure
Return to Work
Other
If Other, specify
Additional Notes
Comments