MEDICAL DIAGNOSTIC CHOICES, MDC-Atlanta

777 Cleveland Avenue, Suite 100

Atlanta, Georgia, 30315

Medical Director: Jackson L. Gates, MD

Telephone #:404-763-0093 or

678-591-6509

 CLIA #: 11D1096873

CONSULTATION FORM

 FOR GENERAL LABORATORY SERVICE

Patient’s name: ___________________   Date of Birth: _______

Gender: Male or Female (Please circle one);

Patient’s unique ID-number:________________

Doctor’s Name: ___________________________       

Medical Practice Address:  __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Patient’s insurance information/address:

(please attach a copy to this form)

____________________________________________________________________________

List of specimen type (s): _________________

Date of specimen collection: __________

Brief clinical history and any additional specific clinical request(s); (please attach medical records as necessary): ____________________________________________________________

_____________________________________________________________________________