Genetics Lab Request Form Mobile App

Included Fields

Customize to add, remove, or edit any of the fields below.

• 

  Name

• 

  Medical Record#

• 

  Sex

• 

  DOB

• 

  SS#

• 

  Address:

• 

  Phone#

• 

  Name

• 

  Institution

• 

  NPI#

• 

  Address

• 

  Phone#

• 

  Fax#

• 

  CC report copies to:

• 

  Name

• 

  Institution

• 

  Fax#

• 

  Name

• 

  Phone#

• 

  Fax#

• 

  Bill patient (Please attach copy of insurance card)

• 

  Name of insured

• 

  DOB

• 

  SS#

• 

  Relationship to Patient

• 

  Phone#

• 

  Bill physician office or laboratory

• 

  Institution/Organization

• ...and More!