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Provider Details
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Name
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NPI #
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Fax results to: (646) 871-6882
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Order Details
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Urgent?
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Clinical Details
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Nature of Specimen
• • •
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Specify site where appropriate
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Procedure
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Required Tests
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Hematology
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Select those that apply
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Biochemistry Profiles
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Select those that apply
• • •
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Biochemistry Tests
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Select those that apply
• • •
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Immunology
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Select those that apply
• • •
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Microbiology
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Select those that apply
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Special Tests
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Select those that apply
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Provider Electronic Signature
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Electronic Signature
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