Emory Medical Laboratories 
Grant Requisition for Subject Results NOT POSTING TO POWERCHART
(Accompanies Specimen)
For all Emory Healthcare patients (clinic or hospital) use ERMS in lieu of this form.
Use this form ONLY when results should be EXCLUDED from posting to the subject's Emory Healthcare medical record or they are non-Emory Healthcare patients or animals. In this situation, use this form instead of ERMS form.
Specimen will not be accepted if form not completed in full
Patient's Name:	Birth Date:		
Age:	Sex:	(MRN non-Emory Healthcare)		
Research Coordinator:	Telephone #:	PIC #:	
Principal Investigator:	Department:		
Contact for critical values:	Telephone #:	PIC #:	
SMARTKEY Grant Account #			
Exclusion of Results in Study Subject's Emory Healthcare Medical Record	

If using this form, subject's lab results will NOT be included in the subject's Emory Healthcare medical record 
(will NOT automatically post in Power Chart.)
Results for non-Emory Healthcare patients and those that are excluded from the study subject's medical record will be sent to the PI.	

                           CLIENT CODE 6400 ONLY	

	
SpecimenCollectionDate

Specimen Collection Time	

Extra Tubes Drawn at coordinator Request: :                 Number of tubes:_________	  Tube Type:___________

Test Name or Test #**             Test Description	  Test Name or Test #**	       Test Description

							

Visit the EML Website for Test Catalog and other information
http://www.emoryhealthcare.org/medical-lab-services/index.html