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