| LAB REQUISITION FORM |
PRACTICE INFORMATION
Practice Name: | Callondoc
Phone number: | 214-305-2717
Fax number: | 469-586-5909
Address : | 750 North St. Paul Street, Dallas, TX 75201
PATIENT INFORMATION
Patient Name: | MickleJo TestUser
Date of birth: | 10 / 06 / 1995
Email: | 214-305-2717
Phone number: | 469-586-5909
Address : | 750 North St. Paul Street, Dallas, TX 75201
| LAB ORDER
Test Name:
HIV Ag/Ab with Reflex
HIV Ag/Ab with Reflex
HIV Ag/Ab with Reflex
HIV Ag/Ab with Reflex
HIV Ag/Ab with Reflex
Test Code: | 123456
ICD 10: | 123456
Order date: | 3/25/2022
Requisition number:
B0112598113
Billing Instructions:
Billing by patient
Order Expiration Date:
07/20/2020 | Do not accept or process lab orders after the expiration date
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IMAGING FACILITY
Facility Name: |
Email: |
Fax: |
Phone number: |
Address: |
Report Instructions: | Please provide the patient with a copy of the report. Fax additional copy to (214) 304-2712
Date: | 10/12/2021
Provider Name: | Dr. TJ thomsan
NPI: | 123456789