Reliancemedlabs

form – Reliancemedlabs

REQUISTION FORM

17774 Preston Road, Dallas, TX 75252

Email :Info@reliancemedlabs.com

CLIA#: 45D2099319

Phone #: (972) 925-0723

Fax#: (866) 230-5899

Please send patient's demographics and copy of insurance card with requistion

Patient Information

Primary Insurance Provider:
Secondary Insurance Provider:
For Self Pay - Who do we contact for payment?
Physician and Facility Information:
MedLife Diagnostic Services: Mobile X-rays, Ekg, Echo-cardiogram, and Ultrasounds (Place and X in the box next to the ordered test and circle the L or R Site when appropriate)

Xrays

Ultrasounds

Cardiology

Please complete all form fields, incomplete requisition form will delay results

Reliance MedLabs is CLIA certified conducting moderate and high complexity testing.

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MedLife Diagnostics Services is a mobile X-ray company providing additional services like EKG, Doppler, Ultra sound etc.

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Contact Us

  • (972) 925-0723 / (866) 230-5899
  • Info@reliancemedlabs.com
  • 17774 Preston Rd Dallas,Texas 75252

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