THIS IS REQUISITION FOR QUEST DIAGNOSTICS ONLY

DirectDx.net
1-888-283-4741

Draw Scheduling: ( optional )

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

PAYMENT INFORMATION

Payment method: CLIENT BILL ONLY/ACCOUNT BILL ONLY

Quest Account #: 97800203

* This requisition is not available for insurance billing.

ORDER INFORMATION

Requisition #:

Order Date:

VOID AFTER

14541

04-07-2022

04-07-2023

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 First

Last Name:

Test Last77657

Sex:

male

DOB:

02/22/1999

Phone:

888-888-8888

Address:

88 Wynn Wy

City:

Pendergrass

State:

Georgia

ZIP:

30567