Toxicology Screening Laboratory Request Form
Patient Information
Name
Patient ID
Date of Birth
Sex
Female
Male
Other
Ward/Location
Requesting Physician
Specimen Details
Specimen Type
Urine
Blood
Other
Date Collected
Time Collected
Requested Tests
Amphetamine
Barbiturates
Benzodiazepines
Cannabinoids (THC)
Cocaine
Methadone
Opiates
Phencyclidine (PCP)
Other
Clinical Information
Date Requested
Physician's Signature