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
27155
20-08-2024
20-08-2025
PHYSICIAN/PATIENT INFORMATION
Ordering Physician:
Physician NPI No:
Full Name:
Email:
Phone Number:
The physician has electronically signed this form.
Patient Information:
First Name:
dasd
Last Name:
ad
Sex:
Male
DOB:
22/02/1990
Phone:
998-988-98989
Address:
sfsdf
City:
sfsf
State:
Florida
ZIP:
99898
ORDER INFORMATION
*LIPID PANEL, STANDARD: 7600,