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THISISNOTATESTREQUESTFORM.
Pleasefilloutthisformandsubmititwiththetestrequestformorelectronicpackinglist.PATIENTHISTORYFORVERYLONGCHAINACYLCoADEHYDROGENASE(VLAD)DEFICIENCY
PatientName
PhysicianDateofBirthPhysicianPhonePracticeSpecialtyPhysicianFaxGeneticCounselorCounselorPhoneSexFM
PatientsEthnicity(checkallthatapply)
African
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