LabCall Mobile Phlebotomy
CLIENT INTAKE FORM
Patient 's Name
*
First Name
Middle Initial
Last Name
Patient's DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient's Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
MINOR : Parent/Guardian /Caregiver
First Name
Last Name
OPTION 1 :Insurance card Direct Upload ** Insurance will be delivered to the lab with your specimen for billing.
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OPTION 2 :Insurance information fill in. ** Insurance will be delivered to the Lab with your specimen for billing.
Referring Physician with Phone number
Preferred Laboratory Facility
Please Select
INCYTE
LABCORP
INTERPATH
PROSSER HOSPITAL
TRIOS HOSPITAL
KADLEC HOSPITAL
LOURDES HOSPITAL
SEND OUT ( KIT TEST ONLY)
OTHER
OPTION 1: Upload LAB Order Requisition
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Option 2: EMAIL Lab Order Requistion. ORDER@MYLABCALL.COM
Option 3: EFAX. Lab Order Requisition 509-398-9389
Patient agreement terms and conditions
*
SUBMIT
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