|
Date of Collection:
|
Time of Collection:
|
|
Time of last dose:
|
|
|
Routine lab draw
|
Fasting Blood Draw:
|
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Collected Off Site:
|
|
|
Urine Specimen Collection
|
Venous Puncture:
|
|
Saliva Point of Care for Alcohol
|
Results of POC ETOH:
|
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Reason for Test:
|
Testing Device Name:
|
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LOT#:
|
Expiration Date:
|
|
Pharmacogenetic Testing
|
|
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Lab orders-tests:
• • •
|
|
|
Who
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Site
• • •
|
|
Attempts
|
|
|
Order Placed
|
Order(s) placed:
• • •
|
|
Discharge
|
|
|
State at Discharge:
|
|
|
Lab Comments or other orders:
|
|
