Ordering ProvidersDoctor's Order and Instructions I.C Bill Patient BillI.CPlease check off service (s) needed for this appointment.Use of this form requires an established account with an Individual Client Number. If you do not have an active I.C. number, please contact us by calling 410-417-7443Physical Test: Paramedical Testing Pre Op Testing Paramedical Testing requires a Doctor’s Order: EKG Labs (Please attach lab form) Urinalysis (Please attach lab form) Height and Weight Visual Acuity 5 Ft Hearing Test Vital SignsAttach lab formChoose File Attach lab formChoose File Pre Op Testing requires a Doctor’s order EKG Labs (Please attach lab form) Urinalysis (Please attach lab form) Vital Signs (BP, P, R, T, PO2)Attach lab formChoose File Attach lab formChoose File Wellness Check: Glucose VitalsSpecial Instructions:PATIENT INFORMATIONPatient Name:Sex: Male FemaleDOBFasting Yes NoPatient NamePatient PhoneReferring Physician:EmailNPI#PhoneDate TimePLEASE LIST YOUR OFFICE/FACILITY/LOCATIONFull NameSubmit Form
