Express Medical Lab
Test Requisition / Lab-Test Order Form
Client Account & Contact Info
Path Group ID: 302692 Quest Diagnostics ID: 74490936 Express Medical Lab LLC 20 Baker Road, Suite 8 Newnan, GA 30265 (770) 683-0601 E.M.L@ExpressMedicalLab.com Info@ExpressMedicalLab.com
Ordering Physician & Contact Info
NPI#: 1841317138 Bennett, Ray B Wingard Urgent Care 1325 Commerce Dr, #200 Peachtree City, GA 30269 (770) 692-7575
Patient Information
Date of Birth
*
-
Month
-
Day
Year
Date
Biological Sex
*
Male
Female
Full Name
*
First Name
Middle Name
Last Name
Suffix
Back
Next
Contact Information
Company
Email
*
Confirmation Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Test Selection
Select the test(s) you want to Order:
*
Sort By
Name: A to Z
Name: Z to A
Price: Low to High
Price: High to Low
Clear Sort
prev
next
( X )
Anemia Panel
$
95.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Blood Type ABO
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Breath-Alcohol-Content (BAC)
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
CBC / Diff
Complete Blood Count
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
CMP
Complete Metabolic Panel
$
55.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
C-Reactive Protein
$
65.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Cortisol Level
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Diabetic Panel
$
85.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Digoxin Level
$
65.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Electrolyte Panel
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Glucose Level
$
45.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Hemoglobin A1C
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Hepatic Panel
$
55.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
HIV
$
65.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
INR / Prothrombin
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Lipid Panel
$
65.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
MMR
$
55.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Potassium Level
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
PTT
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Rheumatoid Factor
$
65.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
STD Panel
$
150.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
STD+ Panel
$
275.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Testosterone Total
$
75.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Thyroid Panel
$
75.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
TSH
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Urinalysis
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Urine Culture
$
55.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Vitamin B-12
$
55.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Vitamin D25
$
65.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Null-TestingPurposes
$
Free
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Credit Card
Test(s) Ordered / Paid Date
-
Month
-
Day
Year
Date
Please verify that you are human
*
Thank you for choosing Express Medical Lab for your lab test ordering service! Now that you have purchased the type of test(s) that you want to have done, you can visit our lab, or one of our partner labs, to have the necessary test specimens drawn for your labs. Just be sure to print this entire form and take it to the lab you plan to have your blood (or other specimen) drawn, to show that you have prepaid for your test(s). Express Medical Lab 20 Baker St., #8 Newnan, GA 30265 (888) 880-3117 www.ExpressMedicalLab.com Quest Diagnostics (866) 697-8378 www.QuestDiagnostics/Locations/Search.com CLIENT BILL ONLY! No patient or 3rd party billing!
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform