OFDTK-11469 ORAL FLUID DRUG TEST KIT REQUEST FORM ORDERING PROVIDER INFORMATION Joseph Gautreaux III, MD ACCT#11469 1302 Williams Blvd Kenner, LA 70062 Phone: (504) 464-8683 Email: josephgautreaux200@gmail.com PATIENT INFORMATION * * *DOB: *GENDER: MALEFEMALE *RACEASIANAFRICAN AMERICAN / BLACKCAUCASIAN / WHITEHISPANIC / LATINONATIVE AMERICAN / ALASKAN NATIVENATIVE HAWAIIAN / OTHER PATHIFIC ISLANDERMIXEDOTHER *ETHNICITYHISPANIC OR LATINONOT HISPANIC OR LATINOOTHER * * *STATEAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth <tr>CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming * * * * PRESCRIBED MEDICATION *Please hold CTRL button for multiple selection on desktop OS Brand -Brand-AbilifyActiqAdderallAlepamAmbienAtivanAventylAvinzaBelbucaBeneficatBunavailBuprenexButransCannabidiol Oil/ExtractCatapresCelexaCitalopramClorazepateConcertaCymbaltaDalmaneDarvocetDarvonDazidoxDemerolDepraxDesoxynDesyrelDexedrineDextroamphetDextrostatDiastatDidrexDilaudidDolgicDolophineDuraclonDuragesicDuramorphEdluarEffexorElavilEmbedaEndepEndocetEquanilEtrafonEvekeoEvzioExalgoFanatrexFentoraFexmidFioricetFiorinalFlexerilFocalinGabaroneHalcionHorizantHycodanHydrocetHydrostat IRHysinglaIntermezzoInvegaInvega SustennaInvega TrinzaKadianKapvayKlonopinLevateLevorphanolLexaproLibriumLimbitrolLorcetLortabLyricaMarinolMaxidoneMedical MarijuanaMeprospanMetadateMethadoseMethylinMiltownMolipoxinMorphaBond ERMS ContinMS ERMSIRMydayisNarcanNeogabNeurontinNexiclonNorcoNorpraminNucyntaNumorphanNupentinOleptroOpanaOramorphOxectaOxy IROxyContinOxyfastPaliperidonePamelorPaxilPercocetPercodanPercolonePertofranePexevaPrimidoneProzacPrudoxinReprexainRestolinRestorilReviaRisperdalRitalinRohypnolRoxanolRoxicodoneRyzoltSarafemSeconalSeraxSeroquelSilenorSolfotonSomaSonataStilnoxSublinoxSublocadeSuboxoneSubutexTalwinThombranTofranilTranxeneTrazorelTrezixTriavilTrileptalTritticoTryptanolTussionexTylenolTyloxUltracetUltramValiumVicodinVicoprofenVIVTROLVyvanseWellbutrinXanaxXtampza ERZenzediZohydro ErZoloftZolpimistZonalonZubsolvZydone Generic -Generic-9-HydroxyrisperidoneAlprazolamAmitriptylineAmphetamineAmphetamine-ConcAripiprazoleBuprenorphineBuprenorphine-ConcBupropionButalbitalCarisoprodolChlordiazepoxideCitalopram/EscitalopramClonazepamClonidineCodeineCyclobenzaprineDesipramineDextrorphan/LevorphanolDiazepamDihydrocodeineDoxepinDuloxetineFentanylFentanyl-ConcFlunitrazepamFluoxetineFlurazepamGabapentinHaloperidolHydrocodoneHydrocodone-ConcHydromorphoneHydromorphone-ConcImipramineLorazepamMarijuana MetaboliteMeperidineMeprobamateMethadoneMethadone-ConcMethamphetamineMethylphenidateMidazolamMorphineMorphine-ConcNaloxoneNaloxone-ConcNaltrexoneNC/GLUCOSE TOLERANCE 3 HRNordiazepamNortryptilineOxazepamOxcarbazepineOxycodoneOxycodone-ConcOxymorphoneOxymorphone-ConcParoxetinePentobarbitalPhenobarbitalPregabalinPropoxypheneQuetiapineRisperidoneSecobarbitalSertralineTapentadolTemazepamTHC-COOHTramadolTrazodoneVenlafaxineZaleplonZolpidem PATIENT INSURANCE *PATIENT HAVE INSURANCE YESNO * * * *PATIENT RELATIONSHIP TO INSURED SELFCHILDSPOUSEOTHER *BILL CLIENTBILL PATIENT ORDERING PHYSICIAN INFORMATION * *