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Hormonal Test - Lab Request Form
Patient & Referral Physician Information
Your Name
Sex
Male
Female
Date Of Birth
Phone Number
Name Of Referral Hosp/Clinic
Name Of Physician
Email Address
Today's Date
Today's Date
Emergency (Within An Hour)
Urgent (Within 24 Hours)
Within 7 Days
Select Lab Tests Required
FT3
FT4
LH
FSH
TSH (Euthyroid)
TSH (Hyperthyroid)
PRG (Women (1) Follicullar Phase)
PRG (Women (2) Luteal Phase)
PRG (Women (3) Ovulation)
PRG (Women (4) Menopause)
Prostate-Specific Antigen (PSA)
Other Test (Specify)
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