Version: DPH Lab COVID Requisition Form 2021.02.10 Page1
CITY AND COUNTY OF SAN FRANCISCO
PUBLIC HEALTH LABORATORY
101 Grove Street, Room 419
San Francisco, CA 94102 THIS SPACE IS FOR LABORATORY USE ONLY
Tel: (415) 554-2800 Fax: (415) 431-0651
CLIA ID # 05D0643643
Director: Godfred Masinde, PhD
COVID-19 and INFLUENZA A+B TESTING REQUISITION FORM
• ALL FIELDS ON THE FORM ARE FEDERALLY MANDATED. EVERY FIELD MUST BE
COMPLETED OR SPECIMEN WILL BE REJECTED.
• Please type or print legibly.
• This form is intended for COVID-19 test requisitions only.
• Please include a printed copy of this form with the specimen submission.
• For electronic copies of this form, please visit our webpage at: https://www.sfcdcp.org/public-health-lab/forms-
• For guidance on specimen collection and storage, please refer to SFDPH’s Clinical and Testing Guidance:
• Hospitals and large health systems are asked to provide transport of specimens to PHL between the hours of 8
AM and 8 PM Monday-Friday and 9 AM to 5 PM Saturday-Sunday. If you do not have the capacity to transport
specimen, SFDPH can arrange for scheduled transport. Please contact the Communicable Disease Control Unit
(CDCU) between the hours of 8 AM and 5 PM at (415) 554-2830 and follow the automated instructions to
• Testing guidelines are subject to change. Please refer to the latest advisories here: https://www.sfcdcp.org/health-
PLEASE COMPLETE REQUISITION FORM ON REVERSE SIDE. PLEASE ATTACH A COPY
WITH THE SPECIMEN.