Home Visit Requisition Form

Date/Time

Physician Information

Patient Information

Insurance Information

A.M.A. Panels

Test 10
Includes: Na, K, Cl, CO2
Test 270
Includes: Na, K, Cl, CO2
Test 11
Includes: Na, K, Cl, CO2, Glu, BUN, Cr, Ca
Test 38
Includes: Trig, Chol., HDL, LDL calc, VLDL calc, Ratios
Test 12
Includes: Na, K, Cl, Glu, BUN, Cr, CA, TP, Alb, TBil AP, AST, ALT, CO2

Other Panels

Test 29
Includes: T4, T3Uptake, FTI, TSH
Test P20
Includes: CBC, B12, FOLATE, IRON, TIBC, RETIC
Test 62
Includes: T3p, T4, FTI, T3, FT4, TSH
Test 2254
Includes: HBSAG, HBSAB, HBcAB, Hav, HCV
Test 39
Includes:
Test P123
Includes:
Test GTT2
Includes:
Test 983
Includes:
Test 24
Includes: GLU, HGB A1C
Test Y19
Includes:
Test 31
Includes: CBC, ANA, ASO, CRP, RF, ESR, URIC ACID

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