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TEST REQUISITION

Laboratory / Account Information9410 Carroll Park Drive San Diego, CA 92121 TOLL FREE: (888) 423-5227 PHONE: (858) 824-0895 FAX: (877) Nestl Health Science CompanyTEST REQUISITIONPLEASE PRINTP atient Information (required) LAST NAME FIRST NAME MIADDRESS APT. STATE ZIPHOME PHONE # OTHER PHONE #DOB SEX M F SSNP rovider / Account InformationACCOUNT NAME / ADDRESSPHONE FAXPROVIDER / NPI #ICD-9 CODES (required)CLINICAL DIAGNOSISDATE COLLECTED (required):TIME COLLECTED:PATIENT ID #SENDER SAMPLE ID #MEDICARE ONLY - HOSPITAL STATUS WHEN SAMPLE WAS COLLECTED Hospital Inpatient Hospital Outpatient Non-Hospital PatientLABORATORY NAME / ADDRESSPHONE FAXCONTACTRESULTS Mail Fax No result

SHIPPING INSTRUCTIONS: Prometheus has an agreement with FedEx Express® for priority overnight delivery service within the United States and Canada. Please call FedEx to schedule a pickup at 1-800-GoFedEx (463-3339). FedEx will pick up your specimens and ship them to Prometheus in San Diego at no expense to you.

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