Lab Requisition Form


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Region 13 RPR Rubella Sed Rate Tacrolimus Testost, total Throat-Strep A Cult TSH TSH/Reflex to FT4 T4 Free Uric Acid Urinalysis Urine micro on pos Patient Name: DOB: MCMG Primary Care Physician: Diagnosis: ICD-9 Code (REQUIRED): Referring Provider: Phone: CC: Results to: Quest Acct (Care360 users): or Fax (non-Care360 users): Signature: Date: MemorialCare Medical Group provides professional services exclusively on behalf of MemorialCare Medical Foundation Rev.10/11.


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