OFDTK-54353

    ORAL FLUID DRUG TEST KIT REQUEST FORM

    ORDERING PROVIDER INFORMATION

    Plaquemines Primary Care ACCT#54353

    27136 Highway 23

    Port Sulphur, LA 70083

    Phone: (504) 564-0848

    Email: mcartagena@plaqueminesmedicalcenter.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

    SELFCHILDSPOUSEOTHER

    *BILL CLIENTBILL PATIENT

    ORDERING PHYSICIAN INFORMATION

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