CLCS - 6Th Floor Wohl Clinic, Room 6619 Phone: 314-362-3522 Fax: 314-362-4782 Email

Standard Clinical Chemisty Requisition

LS-FRM-11.041.3

General Form

CLCS - 6th Floor Wohl Clinic, Room 6619 Phone: 314-362-3522 Fax: 314-362-4782 Email:

Date: / Study:
CARS protocol No: / Investigator:
Subject ID: / Collection Date/Time: / Drawn by:
Gender: / Male / Female
/ DOB: / Visit:
Coordinator: / Phone
Fax: / Email:
GCRC Batteries
Indicate Test(s) by checking (√) the appropriate box. Color of tube to send for testing is indicated in box under “C.”
√ / Test Name / C / √ / Test Name / C / √ / Test Name / C
Basic Metabolic Panel / G / Hepatic Function Panel / G
Comprehensive Metabolic Panel / G / Lipid Panel / G
Electrolyte Panel / G / Renal Function Panel / G
Princ Individual Tests
Indicate Test(s) by checking (√) the appropriate box. Color of tube to send for testing is indicated in box under “C.”
√ / Test Name / C / √ / Test Name / C / √ / Test Name / C
Albumin / G / FT3 / G / TSH / G
Alkaline Phosphatase / G / FT4 / G / Uric Acid / G
ALT / G / Gamma-GT / G / Vitamin D, 25-OH / G
AST / G / Glucose / G
Apolipoprotein A1 / G / HgbA1C (whole blood) / L
Apolipoprotein B / G / HDL (Direct) / G / CBC / L
Bilirubin, Direct / G / hsCRP / G / CBC/Diff / L
Bilirubin, Total / G / Insulin / G / Hemoglobin / L
BUN / G / LDH / G / Hematocrit / L
Calcium / G / LDL (Direct) / G
Carbon Dioxide / G / Magnesium / G / Urine Microalbumin / U
Chloride / G / Phosphorus / G / Urine Microalbumin/Creatinine / U
Cholesterol / G / Potassium / G / 12 Hr. Creatinine Clearance / U
CK / G / PTH / L / Urine Total Volume:
Creatinine / G / Sodium / G / Start date/time:
Cortisol / G / Total Protein / G / End date/time:
C-Peptide / G / Triglycerides / G
Other assays may be available as batched testing. Please contact CLCS for information on batched testing.

G – Green top Vacutainer tube L – EDTA lavender top Vacutainer tube U – Urine

Other Testing Requested:
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Standard Clinical Chemistry Requisition version 3