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Report Number:		Requisition Status:
Patient Name:
Address:
City, State Zip:
Phone:
Email:
Room/Bed:
Floor:
Date of Birth:		Referring Physician:
Sex Code:		Patient Age:
Patient ID:		Demography Id:
Collected:		Reported:
Fasting:		Original Report Date:
Comment:

 

Test Results
Test		Result	Abnormal	Expected