Lab Collections – DNTP LAB

Patient Information

Patient Name:

Date of Birth:

Address:

City, State, ZIP:

Phone Number:

Email Address:

Do you have Medicare -Yes/No, If is yes complete below Insurance Information
Insurance Information

Insurance Name:

Insurance ID/Policy Number:

Medicare, Part B

Self Pay- 1.Credit card 2 Cash 3. Other:

Collection Details:

Date of Collection:

Time of Collection:

Sample Collection address:

Physician Name:

Notes/Special Instructions:

To process your Service Request, we need some documents including, insurance details and lab orders.

Please upload the Front of th insurance card

Please upload the back of th insurance card

Please Upload the lab order

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