LAB ORDER
Rita Stanley M.D.
Doctors’ Clinic of K.C., LLC
1805 NW Platte Road, Ste. 115 Riverside, MO. 64150
816/309-8774 fax 800/556-4966
LAB ORDER (Women)
Dear Patient:
This is an official lab form generated from Dr. Rita Stanley to have lab work done prior to your 1st visit, annually or as ordered by Dr. Stanley.
Your primary care physician may have to order this lab depending on your insurance coverage; please call the benefits number on your card or your primary care office for instructions.
It is important to have them INCLUDE ALL THE INFORMATION ON THIS LAB REQUEST FORM and include Dr. Stanley’s name. This will assure that we obtain a copy of the lab work before your office visit. Notify Dr. Stanley once blood has been drawn: dckcstanley@
PATIENT NAME: _____________________________ Date ___________________________
DOB: ________________________________________________________________________
TELEPHONE NUMBER: _______________________________________________________
Mammogram in past 12mths required before treatment***
PRE-TREATMENT/ANNUAL LEVELS: have ALL tests done
FSH TSH free T3 free T4 reverse T3
Estradiol Testosterone (free & total) Progesterone
DHEA-S Cortisol TPO (thyroid peroxidase antibody)
25 hydroxy Vit D (total) hs-CRP hemoglobinA1c
ICD-10:
N95.1 E34.9 E07.89 E27.40 E72.10 R79.0 E78.5 E55.9
Please have these labs performed and faxed to: (800) 556-4966
Rita C. Stanley, M.D. Mo. License R9J37 NPI 1225149537
LabCorp acct #: 24815890
Quest Diagnostics acct # : N44219
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