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 * * *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 * *