Request Date/Time

* Requestor’s First Name

Requestor’s Last Name

* Client

* Email

Address

* Direct Phone # / Ext

Pickup Date

My specimen pickup request is:

Routine/Will-Calls

Your STAT pickup request must be called into Dispatch at 585/922-1165

-OR-

STAT (Each STAT requires its own submission)

Patient Last Name Newborn Baby Bilirubin Destination Lab

Special Instructions