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Instructions for patient: Please take this order form to your local laboratory for blood draw. Ensure you bring your insurance information and I.D. with you.
Instructions for lab:
Your Fax Number
*Your Email Address
Patient Information:
*First Name
*Last Name
Date of Birth
*Phone Number
Address
State
Zip
Medical Provider Information:
*Medical Providers name
NPI#
Signature
Date
Lab Orders:
--- Select ---
Standard order set #1
Standard order set #2
Standard order set #3
Additional Labs:
Dx Code:
Submit
Home
About Us
Services
Purpose & Procedures
Faxable Lab Form
Blogs
Book An Appointment
Contact Us
Login
Register