Request for Lab Services

Please complete the information below to request laboratory testing, such as those required for College of Nursing and other health programs.

Available tests: Titers for Measles, Mumps, Rubella, Varicella, Hepatitis B & TB Quantiferon Gold Blood Test

The order for testing will be sent to Quest Laboratories within 24 hours of your request (Monday-Friday only). You will receive an email at your Lewis University email address with confirmation of tests ordered and instructions.

*Student Last Name:

*Student First Name:

*Birth Date:

*Sex: 
 Female
 Male

Phone Number:

University ID Number:

Lewis University Email:

*Student Type: 
 Off-campus commuting student (Please provide current address)
 On-campus Residential Student (indicate specific Residence Hall)

If commuting student, provide current location with Street/City/State/Country
Street:  
City: 
State:  
Country: 

If resident student, please provide residence hall:

*Please indicate which tests you need to schedule.
 Measles Titer ($10.00)
 Mumps Titer ($10.00)
 Rubella Titer ($10.00)
 Varicella Titer ($10.00)
 Hepatitis B Titer ($15.00)
 TB Quantiferon ($55.00)

Draw Fee ($5.00)
This fee will be charged to your student account.

Security Password (Please type the word ):
Invisible line, width of the page