THIS IS REQUISITION FOR LABCORP ONLY

DirectDx.net
1-888-283-4741

Draw Scheduling: ( optional )

Call 888-522-2677

* CLIENT BILL ONLY NO PATIENT OR THIRD PARTY BILLING ON THIS ACCOUNT *

PAYMENT INFORMATION

Payment method: CLIENT BILL ONLY/ACCOUNT BILL ONLY

Labcorp Account #:

* This requisition is not available for insurance billing.

ORDER INFORMATION

Requisition #:

Order Date:

VOID AFTER

14194

19-05-2022

19-05-2023

PHYSICIAN/PATIENT INFORMATION

Ordering Physician:

Physician NPI No:

Full Name:

Email:

Phone Number:

The physician has electronically signed this form.

Patient Information:

First Name:

test

Last Name:

test

Sex:

Male

DOB:

09/03/2001

Phone:

345-678-9033

Address:

Teston Ln

City:

Vidalia

State:

Georgia

ZIP:

30474