OFDTK-42166

    ORAL FLUID DRUG TEST KIT REQUEST FORM
    ORDERING PROVIDER INFORMATION

    Paragon Pain And Rehab ACCT#42166

    2895 Lewis Ln

    Paris, TX 75460

    Phone: (972) 203-3600

    Email: info@paragonphp.com

    PATIENT INFORMATION
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    *DOB:
    *GENDER: MALEFEMALE
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    PATIENT INSURANCE
    *PATIENT HAVE INSURANCE
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    *PATIENT RELATIONSHIP TO INSURED
    SELFCHILDSPOUSEOTHER
    ORDERING PHYSICIAN INFORMATION
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