Laboratory Testing Order Form
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213 Providence Road ~ Eastowne Hills Executive Offices
Chapel Hill, North Carolina 27514
919-419-9099 ~ fax: 919-419-9049
drgangemi@drgangemi.com
Laboratory Test Kit Order Form and Waiver
| Name: _______________________________________ |
| Street Address: _______________________________________ |
| City: ______________ State: ______ Zip: _________ |
| Day Phone: _________________ Evening Phone: ________________ |
| Email: __________________________ Fax: _________________ |
Name of test(s) you wish to order (mark all that apply):
Total cost: ___________
Payment Method: Visa * M/C * Discover *Check (we will not send kits out until check clears)
Credit Card #:________ -________ -________ - ________ Exp: ____/______
Zip code where bill is sent: ________
Waiver:
By signing below you understand that the laboratory test kit(s) you are ordering is for your personal information and for your doctor’s information only. Although Dr. Gangemi will send a brief explanation along with your results, he in no way is responsible for the information provided. A lab test alone is not intended to diagnose or base any treatment regimen off of; they are used in conjunction with other criteria including a complete exam, history, and evaluation to get the clearest picture of your health. Dr. Gangemi is only responsible for the information provided with tests he runs on the patients he physically sees in his office. Therefore, you should consult with your health care provider on the results of your lab test.
Signed: _________________________________ Date: ___________
Printed name: _________________________________
