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

    *

    *

    *

      

    *

    *

    *

    *

    *

    *

    PRESCRIBED MEDICATION

    *Please hold CTRL button for multiple selection on desktop OS

    Brand

    Generic

    PATIENT INSURANCE

    *PATIENT HAVE INSURANCE
    YESNO

    *

    *

    *

      

    *PATIENT RELATIONSHIP TO INSURED

    SELFCHILDSPOUSEOTHER

    *BILL CLIENTBILL PATIENT

    ORDERING PHYSICIAN INFORMATION

    *

    *