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 * * *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 CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming * * * * PATIENT INSURANCE *PATIENT HAVE INSURANCE YESNO * * * *PATIENT RELATIONSHIP TO INSURED SELFCHILDSPOUSEOTHER ORDERING PHYSICIAN INFORMATION * *