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

:

FAX COMPLETED FORM TO: 732-321-1150 AVANTIC CLIENT SERVICES DEPT.

Depending upon the type of specimen, samples are usually held from 2-10 days.

FORM MUST BE COMPLETED IN ITS ENTIRETY FOR PROCESSING OF REQUEST.

This document contains private and confidential health information protected by State and Federal Law.
If you have received this document in error, please call 732-474-1120

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.

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Request For Add On Testing