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Test Request Forms

Test Request Forms

The Bureau of Laboratories' test requisitions are updated frequently. Please download and use the most recent version.

Download a test requisition form from the selection below: 

For best printing of forms, use the print button on the PDF 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 (Rev. 6-22)
  • CD4/CD8 & HIV-1 viral load testing, MDHHS-6084 (New 2-24)
  • CDC Specimen Submission Form (NOTE: Submitters must use these forms; Forms and specimens must be sent to the MDHHS Bureau of Laboratories for forwarding to CDC)
  • Chlamydia trachomatis/Neisseria gonorrhoeae/Trichomonas vaginalis (non-culture), DCH-1248 (Rev. 8-20)
  • COVID-19 (SARS-CoV-2) Sequencing Requisition, MDHHS-5905 (Rev. 2-21)
  • Environmental Lead Sampling, DCH-0558 (Rev. 11-22)
  • Influenza SARS-CoV-2 Multiplex Assay, MDHHS-6097 (New 2-24)
  • Microbiology/Virology, DCH-0583 (Rev. 01-19) 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 (Rev. 6-22) (Food Outbreak or Non-Human Specimens Only)
  • Rabies Testing, DCH-1053 (Rev. 11-22)
  • Sentinel Physician, DCH-1583Sent (Rev. 01-19)
  • Tick Identification and Test Instructions (Rev. 03-21)
  • Vaccinia/Variola/Pox Virus, DCH-1396 (Rev. 3-22)
  • Viral Respiratory Testing, MDHHS-6097 (New 2-24)
  • Virology/Serology Testing, MDHHS-6084 (New 2-24)
 

The following test requisitions cannot be downloaded from this site. Ordering instructions are listed for each requisition. 

There is a fee associated with some testing. The following test requisitions must be ordered from Accounting.
  • Medical/Nursing Student/Healthcare Worker Immune Status Antibody Testing - DCH-0459. To order, please email Stacy Groff at groffs@michigan.gov.
  • Newborn Screening - DCH-1153 and DCH-1154 To order, please call 517-335-8110
 

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

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

Rev.  03/24/2025