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Irology M 1. 2. 3. 4. 5. D.O.B. F NPI # ORDERING PHYSICIAN / PHONE # LOGGED IN BY: Chlamydia, viral and routine microbiology transport media MAY NOT be used interchangeably. Dacroswab (type 1) recommended for viral cultures. Culturette recommended for PCR detection from mucosal surfaces. Pur-Wrap swab recommended for chlamydia cultures. Reflex tests instructions can be found on back. Additional charges will be incurred fo reflex testing. VIRAL CULTURE & ANTIGEN DETECTION (206 987-2088.

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  2. Fill in the patient number (PT. NO.) and assign it a unique identifier for tracking purposes.
  3. Enter the patient's name in the format of Last name, First name. This identification is essential for the processing of tests.
  4. Provide the patient's date of birth (D.O.B.) to confirm their identity and relevant age-related information.
  5. Input the NPI number of the ordering physician, as this is critical for billing and proper test administration.
  6. Specify the specimen type from the available options, ensuring the sample aligns with the required tests.
  7. Select the specific tests needed by checking the appropriate boxes. Make sure to consider any additional tests that may be beneficial.
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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232