Mobile Phlebotomy Request

Request Concierge Mobile Phlebotomy Service
Please Note

In-person appointments are available at our draw center:

📍 14340 Bolsa Chica Road, Suite F, Westminster, CA 92683

🕘 Monday–Friday | 9:00 AM–3:30 PM

For urgent requests, please contact the draw center directly at (714) 804-5109.
This Blood Draw is for:
Patient Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Requesting service for someone else

If you are requesting Lions mobile phlebotomy services for someone else, please provide the information below.
Requester’s Information
Requester’s Full Name

First NameLast Name
Requester’s Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient's Information
Patient's Full Name

First NameLast Name
Patient’s Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient’s Date of Birth

MonthDayYear
Patients Email
example@example.com

Appointment Details
Desired Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearMonday - Friday Only
Please select your preferred timeframe for your appointment.

The final appointment time will be confirmed with you via email and included in your invoice.
Please select one option.
Location Type
Location for Mobile Blood Draw

Street Address Line 1

Street Address Line 2

CityState / Province

Postal / Zip Code
Please provide any additional service information:
Example: Gate codes, parking instructions, patient considerations, etc.

Lab Order

Each test kit includes a lab order.
Choose one option.
Upload Lab Order from your test kit

Cancelof
Payment Method

All mobile draws are cash pay. Your invoice will be included in your appointment confirmation email.
Acknowledgement
Insurance Provider
Policy Number
Medicare ID
Upload Front of Insurance Card
Upload Back of Insurance Card
Upload Government-issued ID
Acknowledgement

Terms and conditions
Cancellation & Rescheduling Policy: A minimum of 24 hours’ notice is required to cancel or reschedule a mobile phlebotomy appointment. Cancellations or rescheduling requests made 24 hours or more before the appointment may qualify for a full or partial refund, depending on the service and applicable fees. Cancellations made less than 24 hours before the scheduled appointment are non-refundable. Mobile travel, scheduling, and administrative fees may be non-refundable.

No-Show & Late Arrival Policy: The phlebotomist will wait a maximum of 10 minutes after the scheduled appointment time. If the client is unavailable, does not provide access to the location, or does not respond within the 10-minute waiting period, the appointment may be considered a no-show and the phlebotomist may leave. No-show appointments are non-refundable, and a new appointment may require payment of a new service fee. By scheduling an appointment, the client acknowledges and agrees to these policies.
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Request Concierge Mobile Phlebotomy Service