Sample Quest requisition

Quest Diagnostics Incorporated Profiles/Tests 482 - Gamma Glutamyl Transferase (GGT) [SERUM] 496 - Hemoglobin A1c [BLOOD] 561 - Insulin [SERUM] 905 - Uric Acid [SERUM] 1759 - CBC (H/H, RBC, Indices, WBC, Plt) [BLOOD] 5224 - Apolipoprotein B [SERUM] 5616 - Iron, TIBC and Ferritin Panel [SERUM] 7600 - Lipid Panel, Standard [SERUM] 10124 - hs-CRP [SERUM] 10231 - Comprehensive Metabolic Panel [SERUM] 17306 - Vitamin D, 25-Hydroxy, Total, Immunoassay [SERUM] 31789 - Homocysteine [SERUM] 34604 - Lipoprotein (a) [SERUM] Page # 1 SAMPLE - NOT SCANNABLE FICTIONAL REQUISITION / REQUETE FICTIVE PSC Hold SAMPLE - NOT VALID CLIENT # / COMPTE : SAMPLE-001 SAMPLE ACCOUNT - NOT ACTIVE 100 Sample Street Presque Isle, ME 04769 207-555-0100 Patient Information MICHAEL SMITH 100 Sample Street Presque Isle, ME 04769 207-555-0142 Collection Date Collection Time 12:04 PM Patient ID DOB / Sex 01/15/1974 M FICTIONAL SAMPLE - identifiers and barcodes have been replaced; requested tests are preserved. Provider Information SAMPLE PROVIDER, PHARMD Provider ID: SAMPLE-P01 NPI: FICTIONAL - NOT ACTIVE Responsible Party / Insurance MICHAEL SMITH Self-pay educational sample No active insurance information This de-identified example is not an active order and cannot be used for collection. Patient acknowledgement / Signature MICHAEL SMITH - FICTIONAL SAMPLE Provider authorization SAMPLE PROVIDER - NOT VALID FICTIONAL SAMPLE - NOT VALID FOR TESTING OR MEDICAL USE SAMPLE-260216 02/16/2026

Quest Diagnostics Incorporated CLIENT # SAMPLE-001 | MICHAEL SMITH | DOB 01/15/1974 - NOT SCANNABLE CONTINUED PROFILES / TESTS FICTIONAL SAMPLE - NOT VALID BARCODE 1 REMOVED SAMPLE - NOT SCANNABLE BARCODE 2 REMOVED SAMPLE - NOT SCANNABLE BARCODE 3 REMOVED SAMPLE - NOT SCANNABLE End of Requisition SAMPLE-260216