OFDTK-44209 ORAL FLUID DRUG TEST KIT REQUEST FORM ORDERING PROVIDER INFORMATION TELE MED CLINIX ACCT# 44209 541 N Palmeto Ave, STE 104 Sanford, FL 32771 Phone: (321) 209-4040 Email: support@telemedclinix.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 * *