Click Here To Download This Form In PDF REQUEST FOR ADD-ON TESTING REQUEST FOR ADD-ON TESTING The United States Code of Federal Regulations Requires a Written and Signed Request be forwarded to our Laboratory When Additional Testing is requested. Account Number : * Account Name : * Patient Name : * Date of Birth (D.O.B.) Specimen Number/Bar Code : Test Number/Numbers : Test Name/Names : Specimen Date : Dx. Code : Medicare Patient ? Yes No Office Fax Number : Email * By signing below I certify that I have read and understood all the terms and conditions: SIGNATURE OF PHYSICIAN (OR AUTHORIZED DESIGNEE) * * By checking this box and typing my name, i am electronically signing my application. Date Time 121234567891011 : 0030 AMPM * Please check here if you would like fax confirmation that request has been received and is in process. Please be advised that you will be notified via fax if we are unable to process you add-on request. Submit If you are human, leave this field blank.