Physician Laboratory Requisition Form | UR Next Lab Service Solutions

UR NEXT LAB AND SERVICES SOLUTIONS, LLC

Point-of-Care & Clinical Diagnostic Laboratories • CLIA Certificate of Waiver #10D2347904

6015 Chester Cir Ste 108, Jacksonville, FL 32217
Laboratory Director: Rashan J. Jones • NPI #: 1538076583
Direct Clinical Dispatch: 1.833.487.6398 • Email: urnext.lab@gmail.com • Web: www.urnextlab.com

1. Patient Demographics & Contact Please print clearly

Patient Full Legal Name (Last, First, Middle)

Date of Birth (MM/DD/YYYY)

Biological Sex / Gender

[ ] M [ ] F [ ] Other

Street Address

City, State, ZIP Code

Jacksonville, FL 322

Patient Telephone / Cell

Patient Email (For Encrypted PDF Results Dispatch)

Insurance Carrier / Self-Pay Designation

[ ] Self-Pay (Transparent Flat Fee) [ ] Commercial / Other

2. Ordering Clinician & Practice Information Physician / PA / NP Order

Ordering Provider Full Name & Title

National Provider Identifier (NPI #)

Practice / Clinic / Facility Name

Practice Address & Suite

Phone Number

Confidential Fax (For Immediate Results Transmission)

3. Specimen Collection & Clinical Details

Date of Collection

____ / ____ / 202___

Time Collected

____:____ [ ] AM [ ] PM

Fasting Status

[ ] Fasting (10-12h) [ ] Non-Fasting

Collection Type

[ ] In-Clinic [ ] Mobile Phlebotomy

Primary ICD-10 Diagnosis Codes / Clinical Symptoms

Special Instructions / STAT Priority

[ ] STAT Expedited [ ] Standard Routine

5. Ordering Clinician Authorization & Attestation

Authorized Clinician Signature

I certify that the diagnostic laboratory tests ordered above are medically necessary for the care and treatment of this patient.

Date Signed

UR Next Lab Laboratory Dispatch Instructions: Please send completed requisition via confidential fax to our clinical intake or present with patient at 6015 Chester Cir Ste 108, Jacksonville, FL 32217. Walk-In Lab Hours: Monday–Friday 8:00 AM – 6:00 PM (Closed for Lunch 12:00 PM – 1:00 PM). Saturday: 7:00 AM – 12:00 PM (Pre-Booked Appointments & Mobile Concierge Draws Only). For mobile phlebotomy pick-up or clinical client inquiries, contact our dispatch line at 1.833.487.6398 or email urnext.lab@gmail.com.