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

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    *DOB:

    *GENDER: MALEFEMALE

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    PRESCRIBED MEDICATION

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    Brand

    Generic

    PATIENT INSURANCE

    *PATIENT HAVE INSURANCE
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    *PATIENT RELATIONSHIP TO INSURED

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    ORDERING PHYSICIAN INFORMATION

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