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Get UT Public Health Laboratories Novel Influenza A (H1N1) Test Request Form 2009-2024

584-8486 LAB#: DATE STAMP: http://health.utah.gov/lab/microbiology TESTING WILL NOT BE PERFORMED UNLESS SLIP IS COMPLETELY FILLED OUT. PLEASE PRINT CLEARLY FOR ACCURACY. PATIENT INFORMATION: Patient Name (Last, First): Patient ID #: DATE OF BIRTH (mm/dd/yy) AGE: SEX: M / / PROVIDER INFORMATION Provider Code: F Physician: SPECIMEN Provider Phone: COLLECTION DATE Provider Email:.

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