Appointment Request And Registration Form

Appointment Request And Registration Form

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Full Name

Prefix First Name Last Name
Contact Number
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Email Address
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
What date and time work best for you?
Any other specific date and time, if the above selection is not suitable.

Month Day Year
Date
Hour Minutes AM/PM Option
What services are you interested in?
For Private Collections, Please Upload The Doctors Order

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Disclaimer
*Please note: This rate includes mileage; additional mileage is added if over 25 miles from Greater Boston (standard rate 0.67 per mile)*
My Products
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Private Home Collection Let our professional phlebotomist come to you*Please note: This rate includes mileage; additional mileage is added if over 25 miles from Greater Boston (standard rate 0.67 per mile)*
$ 145.00 Quantity

Kit Collection Do you have a special blood collection kit like Genova or Vibrant America? Choose the number of kits that you need drawn. We will process the blood work per the requirements of that lab. Package and ship out the specimen using the designated shipping labels.
$ 145.00 Number of Kits
Item subtotal: $ 0.00

Same Day Kit Collection Do you need a same day kit collection? Our mobile healthcare provider will come, collect and process the specimen per that labs requirements. Properly pack and ship the specimen to the designated laboratory.
$ 199.00 Quantity

DNA TESTING (GENDER REVEAL) Know at 6 weeks into pregnancy with our Early Baby Gender At-Home DNA blood test
$ 169.99

Covid Testing (PCR) Fast, reliable and non-invasive RT-PCREasily test for SARS-CoV-2 infection whether you’re symptomatic or asymptomatic. Our mobile health care provider will collect your sample at home results within 4 hours of lab receiving test.RNA from SARS-CoV-2 virus-icon
$ 185.00 Quantity

Therapeutic Blood Draw Therapeutic phlebotomy is a blood draw that's done to treat a medical problem, such as having too much iron in your blood. With therapeutic phlebotomy, more blood is drawn than during a regular blood draw. Your doctor will decide how much blood will be drawn based on the reason you're having the procedure. Quantity starts at 250 ml. We will collect no more than 500 ml per one sitting
$ 375.00 Quantity

Urine Sample Collection
$ 15.00

Total

$ 0.00
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