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INTERNATIONAL MEDICAL

LABORATORY

SAME DAY RESULTS

NO APPOINTMENT

(800) 288-1IML

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Patient First Name

Patient Last Name

Email Address

Date of Birth

Phone

Specimen Collection Date

Specimen Collection Time

Name of Spouse / Partner

Method of Specimen Collection

Days of Abstinence

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International Medical Laboratory, Inc.

For more information, call us at (800) 288-1IML

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