Fillable Laboratory Test Request Form - sbcounty

Description
County of San Bernardino Department of Public Health, Public Health Laboratory 799 East Rialto Avenue, San Bernardino, CA 92415-0011 Phone: (909) 383-3000 Fax: (909) 383-3094 LAB USE ONLY Date Received: LABORATORY TEST REQUEST FORM ALL INFORMATION IN TOP SECTION MUST BE COMPLETED FOR FPACT AND MEDI-CAL CLIENTS (Please Attach a Copy of POS Ticket Printout) SUBMITTER ID#: Name: Address: PHYSICIAN REQUESTING TEST...
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