Lab Agreement and Request Form

Name*

First NameLast Name

Date of birth*

Choose all of the following that apply:*

I have an order from my doctor, physician assistant (PA), or nurse practitioner (NP).*I would like to repeat a test that was previously abnormal.*I would like to set up a 20-minute VIDEO consultation with Dr. Cluff to determine which labs he would recommend (cost: $75; to book an appointment, click the link provided on the Low-Price Labs page in item 3).I would like a test/tests that are recommended by the USPSTF (or other official entity) for screening or public health purposes**Request a pregnancy blood test (HCG quantitative). By checking this box, you are agreeing that if the test is positive you will seek the necessary prenatal care.Request a fecal occult blood (FOB) test (for colon cancer screening). By checking this box, you are agreeing that if it is positive you will obtain a colonoscopy (e.g., from a gastroenterologist). Note that the sample is taken at home, so the kit must either be picked up from our office or mailed to you (mailing costs an extra $10). The kit is be pre-stamped for return through the mail.I would like a B12 test.I would like a testosterone test.

*Please upload the physician order or previously abnormal lab results, if applicable.

NOTE: You or your physician may also fax either to us at 915-331-9481.

**The following are recommended by the USPSTF for screening or public health purposes:

Fasting blood glucose (the screening test for diabetes - part of the comprehensive metabolic panel, or CMP) testing for overweight or obese individuals ages 40-70
Cholesterol (lipid) screening in men (35+) and women (45+) who are at increased risk for coronary artery disease (e.g., high blood pressure, diabetes, obesity, smoking, being sedentary, drinking too much alcohol, diet high in saturated fats, trans fat, and cholesterol, and having a family history of early heart disease)
Gonorrhea and chlamydia testing for sexually active women age 24 and younger, and in older women who are at increased risk for infection
Hepatitis B testing in adolescents and adults at increased risk for infection
Hepatitis C testing in adults aged 18-79 years
HIV (human immunodeficiency virus) testing for adolescents and adults aged 15-65 years
Syphilis (RPR, or rapid plasma reagin) testing in persons who are at increased risk for infection

TSH (thyroid stimulating hormone, for thyroid dysfunction) testing is also recommended by the American Thyroid Association beginning at age 35 years and every 5 years thereafter.

As a reminder, please see our Lab Pricing page for lab options, descriptions, and prices.

Please list/confirm all of the labs you (and/or your doctor) would like to order:*

Please read and and mark each of the following:*

Although results are usually highly accurate, I understand that my results may contain errors, including false positives and false negatives, or true results that either may be interpreted in different ways or may have little or no clinical significance – and that it is often wise to repeat equivocal or significant abnormalities.I will consult with a qualified physician or other healthcare provider if I receive any abnormal lab results or results that concern me.I understand that health care providers are not liable for following up on the results, unless I consult with one of them (separate charge applies – see above, under "Choose one of the following:", third option).I understand that lab prices are subject to change, and that labs will be billed according to what is posted the day I submit this form.I understand that most labs do not require fasting, other than glucose (contained in the Comprehensive Metabolic Panel) and Lipid (Cholesterol) Panel.I understand that some tests have “reflex” or “confirmatory” testing (each such test is clearly marked, and the cost of the additional testing is listed in the detailed instructions).I understand that my card on file will be charged for the appropriate amount when the labs are ordered. If any of the tests I request have reflex or confirmatory tests that are positive, those charges will be applied prior to receiving the results.

Signature*