Quick Draw Mobile Phlebotomy Service
CLIENT INTAKE FORM
Client Name
*
First Name
Middle Initial
Last Name
Client DOB
*
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Email
example@example.com
Phone Number
*
Please enter a valid phone number.
When Do You Need To Schedule The Appointment?
*
IMPORTANT: To process your samples, the labs require ALL of the following documents: Proof of Insurance, Photo Id and a Lab Order
Below, we provide 3 different options for you to send us your documents.
Option 1: DIRECT UPLOAD of All Required Documents
Proof of Insurance:
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of
Photo ID:
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of
Lab Order
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of
Option 2: EMAIL All Required Documents To: nicci@quickdrawmobile.com
Option 3: FAX All Required Documents To: 509-984-4021
MINOR: Parent/Guardian/Caregiver
First Name
Last Name
Insurance information: Insurance will be delivered to the Lab with your specimen for billing.
Referring Physician with Phone number
Preferred Laboratory Facility
Please Select
SAMARITAN CLINIC
SAMARITAN HOSPITAL
MOSES LAKE COMMUNITY HEALTH
CONFLUENCE
Pricing: Please select all that apply
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Blood draws between the hours of 5am-7am
$
85.00
Blood draws between the hours of 8am-3pm
$
65.00
Same day Service (Stat Orders)
$
120.00
Travel to Warden, Ephrata additional
$
30.00
Travel To Othello additional
$
50.00
Payment Methods
Debit or Credit Card
Please click one of the PayPal options to complete payment and
submit
the form.
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