Helpful Tips Patient Test Results Cards

Order Type: UNMC Physicians Helpful Tips Patient Test Results Card

Front of Card

Back of Card

Select option 1 or 2 for Back of card:
Option 1: Information about your test results will be provided by mail or telephone in 2 weeks.
Option 2: Information about your test results will be provided at your next clinic visit.

Card size is 8 x 5

* Required Fields
Helpful Tips Patient Test Results Card Information:
Is your order a Reprint? *
Yes (no changes) Yes (with changes) No (new order)

Previous Job Number:

1. Clinic Name: *
2. Nurse's Phone Number: *
3. Prescription Refill Fax Number: *
4. Clinic Mailing Address: * (98XXXX Nebraska Medical Center)
5. City: * State: * Zip:   * (Omaha, NE 68198-XXXX)
Requestors Information:
Requestor's Name: * Department: *

Phone: * E-Mail: *

Fax: *Zip: *

Cost Center Number: *

Quantity Requested: * (minimum 40 cards)
Delivery:
 
Building:
Room Number:
ZIP:
Delivery Date:
Proof Requested:
Special Instructions:

Image of Text Type the text on the left
into the space below.

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