Medical Specimen Special Handling Request Form
Patient Information
Patient Name
DOB
MRN
Physician
Contact Number
Specimen Information
Specimen Type
Collection Date
Collection Time
Test(s) Requested
Special Handling Instructions
Frozen
Refrigerated
Protect from Light
Urgent Processing
Other
Additional Instructions
Shipping Information
Courier/Carrier
Tracking Number
Destination Laboratory
Requested By (Name)
Date
Signature