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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    PATIENT INSURANCE
    *PATIENT HAVE INSURANCE
    YESNO
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    *PATIENT RELATIONSHIP TO INSURED
    SELFCHILDSPOUSEOTHER
    ORDERING PHYSICIAN INFORMATION
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