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Your office will be contacted prior to test being performed if form is not complete. ICD-10 CODE PATIENT SIGNS/SYMPTOMS PHYSICIAN NAME please print CALL REPORT TO FAX REPORT TO X SPECIAL INSTRUCTIONS ORDERING PHYSICIAN S SIGNATURE DATE/TIME Signature Stamps Are Not Valid GENERAL LAB TEST acetaminophen acetone qual albumin alk phos ammonia amylase b12 bilirubin total bilirubin dir bun c-reactive protein calcium chloride cholesterol creatinine ethanol serum d-dimer ferritin fibrinogen folate...
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