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
27159
27-08-2024
27-08-2025
PHYSICIAN/PATIENT INFORMATION
Ordering Physician:
Physician NPI No:
Full Name:
Email:
Phone Number:
The physician has electronically signed this form.
Patient Information:
First Name:
Mohsin
Last Name:
khan
Sex:
Male
DOB:
12/10/1995
Phone:
1234567891
Address:
City:
State:
ZIP:
ORDER INFORMATION
*LIPID PANEL, STANDARD: 7600,