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Get and Sign Form 1281 2008
NON-HISPANIC
CITY
STATE ZIP
COUNTY
(AREA CODE) PHONE
CITY
STATE ZIP
COUNTY
(AREA CODE) PHONE
(AREA CODE) FAX
ORDERING FACILITY NAME
NUMBER
STREET
SUITE
DATE SPECIMEN COLLECTED
TYPE OF SPECIMEN
Sputum
Blood
CITY
STATE ZIP
DATE SPECIMEN RECEIVED
COUNTY
DATE RESULTED
Stool
Pharyngeal Swab
CSF
Washing
(AREA CODE) PHONE
LAB ACCESSION NUMBER
Discharge
Other (Specify) __________________________
SITE OF SPECIMEN (CERVIX, EYE, ETC.)
NAME OF TEST
TEST NUMBER OR...
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