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DIAGNOSTIC MYCOPLASMA LABORATORY REQUEST FORM SHIP TO University of Alabama Health Service Foundation 1825 University Blvd - SHEL 476 BIRMINGHAM AL 35294 Phone 205-934-9142 FAX 205-975-5965 WEBSITE www. mycoplasma.uab. edu HOURS OF OPERATION M-F 8 00am-5pm FROM PATIENT INFORMATION attach patient label if possible PATIENT NAME DOB MED REC Accn No DATE COLLECTED TIME COLLECTED TYPE OF SPECIMEN source Physician NUMBER AND PERSON TO REPORT CRITICAL R.

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