The image is a photograph of a laboratory request form from BC Biomedical Laboratories Ltd. The form is titled "Laboratory Request" and has the company's logo on the top left corner. 

The form has fields for the patient's name, address, and other relevant information. There is also a checkbox next to the checkbox that says "Allow highlighted fields must be completed to avoid days in specimen collection and patient processing."

At the bottom of the form, there is a space for the applicant's name and contact information. On the right side, there are two fields - "For tests indicated with a blue tick box guidelines and protocols" and "Other".

There are also two checkboxes next to each field - "MSP", "ICBC", and "WorkSafe BC". The form also has a space to fill out the details of the patient, such as the date, time, and location of the procedure.

Overall, the form appears to be a form for a laboratory requirement for a patient to be completed in a specimen collection or patient processing procedure.