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

27844

02-07-2024

02-07-2025

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,