OFDTK-34385

    ORAL FLUID DRUG TEST KIT REQUEST FORM

    ORDERING PROVIDER INFORMATION

    Newhope Addiction ACCT#34385

    215 North Park Drive

    Monroe, LA 71203

    Phone: (318) 977-9100

    Email: intake@nhrecovery.com

    PATIENT INFORMATION

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    *DOB:

    *GENDER: MALEFEMALE

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    PRESCRIBED MEDICATION

    *Please hold CTRL button for multiple selection on desktop OS

    Brand

    Generic

    PATIENT INSURANCE

    *PATIENT HAVE INSURANCE
    YESNO

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    *PATIENT RELATIONSHIP TO INSURED

    SELFCHILDSPOUSEOTHER

    *BILL CLIENTBILL PATIENT

    ORDERING PHYSICIAN INFORMATION

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