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Get Test Requisition Form - BioTheranostics

To request the specimen from Pathology (Please complete and fax this form to (858) 587-5874). ORDERING PHYSICIAN PATHOLOGY INFORMATION Name NPI Name NPI Email Email Practice Name Submitting Hospital/Laboratory Name Address Address City State Phone Zip City Fax State Phone Fax Entering fax # certifies fax equipment is located in a secure area. PATIENT INFORMATION Zip Entering fax # certifies fax equipment is located in a secure area. SPECIMEN INFORMATION Name DOB Socia.

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