Transcription of BTXNGS142 Met Solution Test Req v27 front - …
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BTXNGS142 Met Solution Test Req v27 front - …
Please include the completed Test Requisition Form, pathology report,& patient insurance card(s) along with the specimenShip to Biotheranostics via FedEx Priority OvernightNameEmailPractice/Facility NameAddressCityStateZipPhoneFaxPATHOLOGI ST NameEmailAddressCityStateZipPhoneFaxName Social Security NumberAddressCityPhoneDOBS tateMedical Record #ZipSex M FBiopsy SiteSPECIMEN INFORMATION Reminder: Has pathologist reviewed tissue for adequacy?Block ID NumberDate Collected Fixative Type (Recommended 10% Neutral-Buffered Formalin)Clinical DiagnosisTESTING SERVICESP ractice/Facility NamePlease check if you are the ordering physicianPlease check if you are the ordering physicianNPINPI2.
Name Email Practice/Facility Name Address City State Zip Code Name Address City Phone DOB State Zip Code Sex M F Biopsy Site V.SPECIMEN INFORMATION Reminder: Has pathologist reviewed tissue for adequacy? SpecimenID Date of Collection
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