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Requisition form laboratory analytics

Clinical Lab Request for download [PDF, 170 KB]


MVZ Dr. Eberhard & Partner Dortmund (ÜBAG)
Laboratoriumsmedizin Dortmund
Brauhausstraße 4
44137 Dortmund, Germany
+49 (0)231 · 9572 - 0

Receipt of material
Mon. - Fri.: 7.30 -17.00


Requisition form

For processing purposes a requisition form must be sent in with every sample. The information on the requisition form [PDF, 170 KB] ensures the exact test specifications, a clear classification of the results and rapid results communication.

Information requisition form

The requisition form has to contain the following information:

  • Patient's surname, first name and date of birth
  • Sender / hospital (stamp), ward for rapid notification of results
  • Type of test material and origin
  • Required tests

The requisition form should also contain the following information:

  • Date / time sample was taken
  • Suspected diagnosis
  • Information on clinical findings, questions, prescribed medication

Please download the form provided here for laboratory analytical requirements from abroad.