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
6692
03-07-2021
03-07-2022
PHYSICIAN/PATIENT INFORMATION
Ordering Physician:
Physician NPI No:
Full Name:
Email:
Phone Number:
The physician has electronically signed this form.
Patient Information:
First Name:
TRACEY
Last Name:
SHARIEFF
Sex:
Female
DOB:
04/15/1966
Phone:
Address:
City:
State:
ZIP:
ORDER INFORMATION
Uric Acid, Serum: 1057, Magnesium, Serum: 1537, Phosphorus, Serum: 1024, Creatine Kinase,Total,Serum: 1362, LDH: 1115, GGT: 1958, Iron, Serum: 1339, Ferritin, Serum: 4598, Lipid Panel w/ Chol/HDL Ratio: 221010, Thyroid Panel With TSH: 620, C-Reactive Protein, Quant: 6627, CBC With Differential/Platelet: 5009, Sedimentation Rate-Westergren: 5215, Vitamin D, 25-Hydroxy: 81950, Comp. Metabolic Panel (14): 322000, Fluorescent treponema Ab, CSF: 828472, Histoplasma Antigen, Urine: 823203, GGT: 1958, Phosphorus, Serum: 1024, LDH: 1115, Magnesium, Serum: 1537, Uric Acid, Serum: 1057, Protein, Total, Serum: 1073, Comp. Metabolic Panel (14): 322000, Iron and TIBC: 1321, Ferritin, Serum: 4598, Thyroid Panel: 455, Thyroid Antibodies: 6684, Hemoglobin A1c: 501518, Lipid Panel: 337877, CBC With Differential/Platelet: 5009,