Online Request Form

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PATIENT INFORMATION
 
Gender:  Male  Female

PROVIDER INFORMATION

SPECIMEN INFORMATION
Fasting:  YES  NO
Stat:  YES  NO

PAYMENT INFORMATION



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IT IS THE ORDERING PARTY'S RESPONS RESPONSIBILITY TO ORDER ONLY THOSE TESTS MEDICALLY NECESSARY FOR THE DIAGNOSIS AND TREATMENT OF THE PATIENT.

List Additional Tests
AFP (Tumer Marker)

Albumin (Alb)

Alkaline Phosphatase (ALP)

ALT (SGPT)

Ammonia, Plasma

Amylase Serum

ANA Screen

ANA Profile

Anti-TPO Ab

Anti-TG Ab

Apolipoprotein A1

Apolipoprotein B

AST (SGOT)

ASO

Basic Metabolic Panel

Beta HCG - Serum

Biliruibin Direct (Dbili)

Bilirubin Total (Tbili)

BNP

BUN / Creatinine Ratio

BUN (Urea Nitrogen) S

BUN (Urea Nitrogen) U

Complement C3

Complement C4

CA 15.3

CA - 19.9

CA - 125

Calcium Serum

Calcium Urine

Carbamazepine or Tegretol

Cardio C- Reactive Protein

CBC (w/diff & platelet count)

CEA

Centromere B

Chloride

Cholesterol

CMV IgG

CO2

Comp Metabolic Panel

Cortisol

C-Peptide

C-Reactive Protein (CRP)

Creatinine with eGFR

Creatinine Urine

Creatinine Kinase

dsDNA Autoantibodies

DHEA-SO4

Digoxin

EBV VCA IgM

EBV VCA IgG

EBV Early Antigen

EBV Nuclear Antigen

Electrolyte Panel

ESR or Sedimentation Rate L

Estradiol

Fasting Blood Sugar


Ferritin

Folate

Fructosamine

FSH

GGT

Glucose Serum

Glucose Urine

Glyco Hgb A1c

HDL

H.Pylori IgG

Hemoglobin/Hematocrit

Hepatic Function Panel

Hepatitis A IgM Ab

Hepatitis A Total Ab

Hepatitis B Core IgM Ab

Hepatitis B Core Total

Hepatitis Bs Ab

Hepatitis Bs Ag

Hepatitis C Total Ab

HSV Type I IgG

HSV Type II IgG

HIV-1/2 Ag/Ab Combo*

Homocysteine

Immunoglobulin E total

Immunoglobulins A, M, G

Insulin

Iron

Jo-1 Autoantibodies

LDH

LDL Direct

Lead

LH

Lipase

Lipid Profile

Lyme Screen lgG

Magnesium Serum

Magnesium Urine

Microalbumin Urine

Microablumin/Creatinine ratio

MMR + V IgG

Non-GYN Cytology, Urine

Occult Blood,Feces

Phenobarbital

Phenytoin or Dilantin

Phosphorus Urine

Phosphorus Serum

PLAC

Potassium (K)

Potassium, Plasma

Progesterone Total

Prolactin

Prostatic Acid Phosphatase

PSA Free

PSA Total

Estradiol

PT/INR


PTH

PTT

Renal Panel

Rheumatoid Factor

RPR (VDRL)

Sci-70 IgG Autoantibodies

SHBG

SmRNP IgG Autoantibodies

Sodium (Na)

SS-A & SS-B IgG Autoantibodies

T3 Free

T3 Total

T3 Uptake

T4 Free

T4 Total - Thyroxine

TBG

Testosterone Total

Theophylline

Thyroglobulin

TIBC

Total Protein Serum

Total Protein Urine

Transferrin

Triglycerides (Trig)

CATSH (High Sensitivity)

Uric Acid Serum

Uric Acid Urine

Urinalysis Complete (dipstick U and microscopic)

Valproic Acid

Vitamin B12

Vitamin D, 25 Hydroxy

   CUSTOM DIAGNOSTIC PROFILES

Allergy Complete Food and Respiratory
Profile (104 Specific Allergens)

Anemia Screen

Cardiac Risk Panel I

Cardiac Risk Panel II

Diabetic Screen

Drug Screen with/without ethanol

Epstein-Barr Virus Screen

Female Health Screen I

Female Hormone Screen

Female Weight Loss Panel

Health Screen II

Heavy Metals

Hepatitis Screen

Male Health Screen I

Male Hormone Screen

Male Weight Loss Panel

Rheumatic Evaluation

Thyroid Antibodies

Thyroid Comp Screen

Initial Cardio Profile

Follow Up Cardio Profile



* HIV Testing will not be performed until a signed patient consent is obtained