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Get microbiology request form sample 2020-2024

Patient First Name: Street: City: St: Zip: Phone: Fax: Date of Birth: Gender: M F UI Diagnostic Laboratories Department of Pathology 200 Hawkins Drive, 5231 RCP Iowa City, Iowa 52242 Toll Free: 866-844-2522 Local: 319-384-7212 Client Services Fax: 319-384-7213 Billing Fax: 319-356-0729 PATH# Completed by: PART B PROVIDER INFORMATION Required Referring Institution: Street: City: St: Zip: Phone: Fax: Referring Physician: Referring Physician Phone: PART C - SPECIMEN INFORMATION.

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