Laboratory Phlebotomy Form

Laboratory Phlebotomy Services

This form is to be filled out by those requesting to receive phlebotomy services from Tomahawk Pharmacy.
Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Date
Gender

FemaleMale
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Appointment*

My Products

Test KitA medical professional has provided you with a test kit. We will draw your sample and ship it to its destination.

$35.00

Ulta Labs Blood DrawThis option is used to book your phlebotomy appointment for a test ordered and paid for through the Ulta Labs website. Please make sure you have ordered and paid for your test through that website before coming in for your blood draw.

$ Free

SneakPeek ClinicalThis option is used to book your phlebotomy appointment for the SneakPeek early gender DNA test for your unborn baby/babies!

$129.00

Enter coupon

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Brand of Test Kit*
Name of Test Kit*
Please read the instructions for your test kit carefully before coming in for your appointment. Some kits require tasks to be completed before shipping (for example, an ice pack to be frozen, etc). If you have any questions regarding the handling of your kit, please let us know. If we have any questions regarding the your type of test kit, we may be reaching out to you prior to your appointment for more information.
Consent for person receiving phlebotomy:*

I consent to have my blood draw by phlebotomy/venipuncture by the trained staff of Tomahawk Pharmacy. I understand that my sample(s) will be mailed to the laboratory for processing, and that my results will be supplied to me by that laboratory that will be receiving the sample.
Signature*

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Laboratory Phlebotomy Services