OFDTK-45920

    ORAL FLUID DRUG TEST KIT REQUEST FORM
    ORDERING PROVIDER INFORMATION

    Bryant Gerard George MD ACCT#45920

    3206 N Turnbull Dr

    Metairie, LA 70002

    Phone: (504) 388-3392

    Email: bryantgeorgesr@gmail.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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