Transcription of General Request Form - Mayo Medical Laboratories
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General Request Form - Mayo Medical Laboratories
Page 1 of 2T239 MC1360rev1118 General RequestClient Information (required)Client NameClient Account PhoneClient Order CodePatient Information (required)Patient ID ( Medical Record No.)Patient Name (Last, First, Middle)Gender Male FemaleBirth Date (Month DD, YYYY)Collection Date (Month DD, YYYY)Time s Street AddressPhoneCityStateZip CodeMML Internal Use OnlyShip specimens to: mayo Medical Laboratories 3050 Superior Drive NW Rochester, MN 55901 Customer Service: 855-516-8404 Billing Information An itemized invoice will be sent each month.
Page 1 of 2 T239 MC1360rev0318 General Request Form Client Information (required) Client Name Client Account No. Client Phone Client Order No. Address City State Zip Code
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