Specialty Lab Order & Kit Instructions (Functional Medicine)

Patient Name: [Patient full name]

DOB: [MM/DD/YYYY]

MRN: [Medical record number]

Encounter Date: [MM/DD/YYYY]

Encounter Type: [in-person / telehealth / phone / portal]

Clinician: [Clinician name, credentials]

Performing Lab/Vendor: [Lab or vendor name]

Lab Contact (logistics): [Lab phone/email/hours]

Clinic Contact (medical questions): [Clinic phone/portal instructions]

Order Summary

(For each test ordered, capture on a single line or short block.)

• [Test/Panel Name]: [Specimen type]; [Collection setting: home kit / in-office / PSC]; [Associated diagnosis/indication with ICD-10 if available]; [Critical timing/handling flags if any]

Clinical Rationale: [Clinical question this testing is intended to answer and how results will inform management decisions]

(Include only if applicable: If clinical utility is uncertain or lacks guideline endorsement, note context and alternatives discussed. If out-of-pocket or coverage uncertain, document cost discussion and patient decision to proceed. For Medicare ABN situations, document ABN status.)

Preparation & Timing

(Omit this section entirely if no special preparation is required.)

[Applicable pre-analytic requirements: fasting status, time-of-day constraints, hydration/activity restrictions, menstrual cycle timing if relevant, medications/supplements to hold with washout period]

Safety: Do not stop prescription medications without clinician approval.

Shipping/Storage: [Shipping constraints and storage requirements per kit insert; if unknown, direct to kit insert and lab support]

Patient Collection Instructions

(This section is written in plain language for direct patient handout.)

[Brief 1–2 sentence summary of what you need to do and by when, including any deadline for shipping.]

1. Confirm the kit is complete and contains all items per kit insert.
2. Write your full name, date of birth, and collection date/time on every container and form.
3. Read all kit instructions before starting. Keep the insert nearby during collection.
4. Collect the specimen exactly as shown in kit instructions, avoiding contamination (do not touch inside of containers; use provided tools).
5. Close containers tightly. Wipe off any spills on the outside.
6. Store the specimen as directed [per kit insert: room temperature / refrigerated / frozen].
7. Place labeled containers and the completed requisition into the biohazard bag. Seal the bag.
8. Package as instructed and ship the same day using the provided mailer. Follow shipping timing on the kit.
9. If you miss the shipping window, do not mail late. Store as directed and ship the next eligible day, or contact the lab.

Troubleshooting:

• Spilled/contaminated specimen: Safely discard and contact the lab for replacement.
• Missed shipping day: Store as directed and ship on the next eligible day. Contact lab if unsure.
• Missing/damaged kit components: Contact the lab for a replacement kit.

For medical questions (symptoms, medication changes): [Clinic contact]. For logistics (kits, labels, shipping): [Lab contact].

Follow-up Plan

Results routing: [EHR inbox / lab portal queue / ordering clinician]

Expected turnaround: [Turnaround time if known, or per lab/kit insert]

Patient notification: [Portal message / phone call / scheduled visit on date]

Abnormal/critical results: [Plan for expedited notification]

Tracking: [Plan if specimen not received within expected window] (Include outreach plan to schedule results review if not yet scheduled.)