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

27739

31-01-2024

31-01-2025

PHYSICIAN/PATIENT INFORMATION

Ordering Physician:

Physician NPI No:

Full Name:

Email:

Phone Number:

The physician has electronically signed this form.

Patient Information:

First Name:

Test

Last Name:

Patient

Sex:

Male

DOB:

01/01/1991

Phone:

1234567890

Address:

Test

City:

Test

State:

Georgia

ZIP:

300089

ORDER INFORMATION
TSH: 4259,
Fasting