Maternal Prenatal Screen Requisition

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Accession # Maternal Prenatal Screen Laboratory Services Client Response Centre 780-407-7484. Requisition Alberta Health Services, Edmonton and Area Personal Health Number (First or Second Trimester Screen ) DynaLIFEDX Diagnostic Laboratory Services M Patient Legal Name (Last) (First) (Initial) D dd Mon yyyy Copy to O. F B Name _________________________. Address City Prov. Postal Code Physician Code __________________. Address ________________________. Chart # Patient Phone # Lab # _______________________________. Bill Type CPL Alberta Health Care Ordering Physician/Practitioner Physician Code Specimen Event Type OR. IA AUXILLARY. IP IN PT CO Company XX Pre-paid Ordering Address / Location Report Location Code OP OUT PT. OT Out of Prov PB Patient Bill AP AMBUL. HC HMCARE Co. name ________________________________________ ____. ST STAFF. Report address if different EN ENVIRON Address ________________________________________ _____. WCB WORKER'S Client # ________________________________________ ______.

Personal Health Number Accession # Maternal Prenatal Screen Requisition (First or Second Trimester Screen) Laboratory Services Client Response Centre 780-407-7484 Alberta Health Services, Edmonton and Area

  Maternal, Screen, Parental, Requisition, Maternal prenatal screen requisition