Download a test requisition form from the selection below: 

For best printing of forms, use the print button on the Adobe Acrobat software instead of your browsers print button. Please note that most forms are two pages.  It is essential to print and submit the entire form.

• Blood Lead Test Request DCH-0696 (Instructions for completing form DCH-0696 ) - updated 4/20/2011 
• CD4/CD8 & HIV-1 Viral Load Testing DCH-0562- updated 4/3/2009 
• CDC Submission Form, CDC 50.34 
• CDC Lyme Disease Case Report Form, CDC 52.60 
• Chlamydia trachomatis/Neisseria gonorrhoeae (non-culture), DCH-1248 - updated 01/10/2012
• Environmental Lead Sampling DCH-0558 (The form prints best using a color printer) - updated 5/5/2011 
• HIV-1 Genotyping DCH-0562- updated 4/3/2009 
• Microbiology/Virology DCH-0583 - updated 7/7/2011  NOTE: This is a 2 page form.  Both pages must be printed, completed and submitted to avoid testing delays.   
• Multiple Patient/Sample - Same Test DCH-1052 - updated 2/2/2012
• PCB & Pesticide Test Request DCH-0571 - updated 9/15/2011 
• Rabies Testing - Lower Peninsula  DCH-1053- updated 8/13/2010  
• Sentinel Physician DCH-1583Sent - updated 9/11/2009 
• Trace Metals Test Requisition DCH-0976 
• Vaccinia/Variola/Pox Virus DCH-1396 - updated 2/2/2012

The following test requisition cannot be downloaded from this site. To order, please contact Mark Warstler at the MDCH Lab Support Unit by Fax 517-335- 9039, phone 517-335-9040, or E-mail at WarstlerMI@michigan.gov.

• Dried Blood Spot; HIV - DCH-0698

The following test requisitions must be ordered by contacting Accounting, as there is a fee associated with the testing. Please call 517-241-5583 for more information.

• Health Care Worker Immune Status Testing- DCH-0460
• Hepatitis C Antibody Screen - FB-202
• Hepatitis C Confirmation - FB-203
• Medical/Nursing Student Antibody Testing - DCH-0459
• Newborn Screening - DCH-1153 and DCH-1154

The following (pre-paid) test requisitions are distributed by the Sexually Transmitted Diseases Section (517-241-0870).

• N. gonorrhoeae and C. trachomatis - Combination - DCH-1167
• C. trachomatis only - DCH-1167

The following instructions provide guidance for collection of clinical specimens for N. gonorrhoeae and C. trachomatis testing

• DCH-0972 - collection of vaginal swabs
• DCH-0973 - collection of rectal and pharyngeal swabs
• DCH-0974- collection of urethral and cervical swabs
• DCH-0975 - collection of urine specimens - added 5/5/2011 

The following test requisition cannot be downloaded from this site. For details regarding ordering, please contact Dr. Bonnie Taffe at 517-335-9490 for more details.

• PBB, PCB, PBDE, and Pesticides Requisition- DCH-0571

Rev.  2/2/2012