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Diagnostic Solutions Sample Requisition

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๐Ÿ–จ๏ธ PLEASE PRINT OUT THE REQUISITION FORM FROM YOUR RUPA PATIENT PORTAL (IF AVAILABLE) AND SEND IT BACK WITH YOUR SAMPLES.

If no requisition form is available in your Rupa patient portal, please fill out the blank form and send it with your samples.

How to Fill Out Your Requisition

PLEASE PRINT OUT THE REQUISITION FORM FROM YOUR RUPA PATIENT PORTAL. You can throw out the blank requisition form included in your kit.

Please note that your requisition may look slightly different depending on the test you ordered. The information you must fill out will be the same no matter how your requisition is formatted.


How Your Completed Requisition Should Look

Please note that your requisition may look slightly different depending on the test you ordered. The information you must fill out will be the same no matter how your requisition is formatted.

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