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COVID-19 RESPIRATORY GASTROINTESTINAL (GI) DRUG TESTING (TOX) PNEUMONIA UTI

Physician Form

PATIENT INFORMATION

First Name
Last Name
Address
City
State
Postal Code
E-mail
Phone
Date of Birth
Gender
Lab Order (MD Order)

INSURANCE INFORMATION

Insurance Card (Front)
Insurance Card (Back)


Secondary Insurance
Insurance Card (Front)
Insurance Card (Back)

CLINICAL/DRUG HISTORY, DRUG INFORMATION

Clinical/Drug History
List of Current Medications

PANELS*

*if you do not know which panels you need, you may skip this section

COVID-19 Coronavirus (SARS-COV2)
Full Drug Panel Without Alcohol
Full Drug Panel With Alcohol
Respiratory Panel
Pneumonia Panel
GI Panel
UTI Panel

TESTING LOCATION

Please call (818) 485-1004 for previously scheduled and missed appointment
Drive Thru - 5400 Balboa Blvd. Encino, CA 91316 (on Clark St)
HOURS: Monday - Friday: 8am - 12pm
Please stay in your vehicle at all times.
Drive Thru - 5400 Balboa Blvd. Encino, CA 91316 (on Clark St)
HOURS: Monday - Friday: 8am - 12pm
Please stay in your vehicle at all times.
Prime Lab - 31344 Via Colinas Unit 104 Westlake Village, CA 91362
HOURS: Monday - Friday: 8am - 2pm
Prime Lab - 31344 Via Colinas Unit 104 Westlake Village, CA 91362
HOURS: Monday - Friday: 8am - 2pm
Date
Time

PHYSICIAN AUTHORIZATION

I authorize the above laboratory test(s). If no profile is selected, Prime Lab will refer to your custom profile for testing an any additional test you have ordered on this form.
I authorize the above laboratory test(s). If no profile is selected, Prime Lab will refer to your custom profile for testing an any additional test you have ordered on this form.
Electronic Signature

 


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© 2024 PRIME LAB   |   ALL RIGHTS RESERVRED

WEBSITE DEVELOPED BY: EMSAR DESIGN LTD