www.marshallortho.com

MARSHALL ORTHOPAEDICS

GOOD SHEPHERD MC / MARSHALL  - OUTPATIENT LAB ORDER FORM

PATIENT NAME :

SS NUMBER :  DATE OF BIRTH:   SEX:

ORDERING PHYSICIAN :   please fax results to 903-935-0077

DIAGNOSIS :

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LAB STUDY :

for specimen collection:

DATE / TIME :  SOURCE:

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Dr's signature : _________

[please attach copy of Marshall Ortho demographic sheet and both sides of insurance card]

I consent to the performance and administration of the above-cited outpatient services by Good Shepherd MC / Marshall.

____________________________________________   ___________________________

signature                                                                     date

______________________________________    ____________________________________

relationship to patient                                       witness

PLEASE FAX RESULTS TO 903-935-0077