Request For Add On Testing

The United States Code of Federal Regulations Requires a Written and Signed Request be forwarded to our Laboratory When Additional Testing is requested. Complete it online to request additional testing with your Avantic Medical Lab account details Or Download the form, complete it, and then submit it to us with the subject line “Request For Add On Testing” to info@avanticlab.com.

Account Number

Account Name

Patient Name

Date of Birth (D.O.B.)

Specimen Number/Bar Code

Test Number/Numbers

Test Name/Names

Specimen Date

Dx. Code

Medicare Patient ?

Office Fax Number

By signing below I certify that I have read and understood all the terms and conditions:

Signature of Physician (Or Authorized Designee)

By checking this box and typing my name, I am electronically signing my application.

Date

Time

FAX COMPLETED FORM TO: 732-321-1150 AVANTIC CLIENT SERVICES DEPT.
Depending upon the type of specimen, samples are usually held from 2-10 days.
FORM MUST BE COMPLETED IN ITS ENTIRETY FOR PROCESSING OF REQUEST.
This document contains private and confidential health information protected by State and Federal Law. If you have received this document in error, please call 732-474-1120

Please check here if you would like fax confirmation that request has been received and is in process. Please be advised that you will be notified via fax if we are unable to process you add-on request.

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