THX Double Blind

Case Information

Case Type:

Collection Date

Recieved Date

Laboratory

Facility

Physician

Lab Case#

Procedure:

Services

Requisition#:

Referring Physician:

Ref. Phy Fax#::

Copy Reports to Referring Physician

Tracking#:

Jars:

ICD10

Quality Attributes

Quality Attributes

Patient Information

Last Name:

Gender:

EMR:

First Name:

DOB:

PMS/PWS#:

Other Information

Site Information

Complete Double Blind