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Cytology Test Request Form

Cytology specimens must be submitted with a completed PLA Cytology test request form. The patient’s first and last name must be printed on the specimen container label or slides, including specimen type for non-gynecological specimens. The following information must be included on the test request form for accurate specimen preparation, interpretation, result reporting, record keeping, and billing (exclusion of any information may result in specimen rejection and/or processing delays):

Patient Name
Date of Birth
Collection Date
Physician’s Name

Source of Specimen Specimen type: Check the space next to the specimen type (e.g. cervical – vaginal smear, gastric brush, bronchial wash or legibly write the source in).
Pertinent Clinical history

This information is required under Federal Regulation CLIA ’88. If the above information is not supplied or if slides are received broken, the specimen processing will be delayed and the ordering physician will be notified.


Document the following information on the test request form in the GYN History Section for required GYN clinical information.

Menstrual history: postmenopausal or last menstrual period (LMP), pregnancy history, hormonal therapy, clinical findings such as abnormal bleeding or discharge, IUD use and previous history of abnormal diagnosis or procedures such as biopsy or cryotherapy.

Check appropriate box and specify if Pap smear is for Screening PAP Test or Patient is High Risk for Cervical Disease.

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