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Get the free Name (First, Last, MI)Date of BirthSex (M/F)

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DIRECT ACCESS TESTING (LAB) ORDER FORM Personal Information (Please Print): Name (First, Last, MI)___Date of Birth___Sex (M/F)___ Address___City___State___Zip___ Phone Number___Results option: ___MyChart
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Start by writing your first name in the designated field
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Follow by entering your last name in the corresponding box
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If applicable, include your middle name or initial in the middle name field

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Individuals filling out official forms, applications, or documents that require accurate identification information
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