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5 (fax) CLIA # 45D0681692 Not Incubated FORM MUST BE FILLED COMPLETELY OR SAMPLE MAY BE REJECTED 1. SUBMITTER INFORMATION Submitter Name Address City, State, Zip Phone Fax Laboratory Contact Name/Number (for questions about the sample) Panic Value Contact Name/Number 2. PATIENT INFORMATION Ordering Physician Date/Time of collection Patient Name (last, first, MI) Address Country of origin City, State, Zip DOB SSN Age Sex Pregnant Yes No Unknown Ethnicity Hispanic Non-Hispanic Unkno.

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