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Courier Hospital Request Form
Please provide the following information to request courier services:
Hospital Information
Hospital Name
Address
Contact Name
Contact Phone
Department
Specimen Information
Number of specimens for pickup
Preferred Lab
Lab Location
Lab Account No.
Requested Date of Service
Requested Pick up Time
What are we transporting?
Please check all of the following boxes that apply to this request
There is at least one
Stat
draw
There is at least one
Routine
draw
Special Remarks
