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
26548
15-03-2024
15-03-2025
PHYSICIAN/PATIENT INFORMATION
Ordering Physician:
Physician NPI No:
Full Name:
Email:
Phone Number:
The physician has electronically signed this form.
Patient Information:
First Name:
Last Name:
Sex:
DOB:
Phone:
Address:
City:
State:
ZIP:
ORDER INFORMATION
ZINC (P): 945, Copper: 363,