Mobile Phlebotomy Request

Concierge Mobile Phlebotomy Request

Upload lab order, enter insurance details, and select appointment time.
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.
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.
Patient's Information
Patient's Full Name*

First NameLast Name
Patient’s Phone Number*
Please enter a valid phone number.
Patient’s Date of Birth*

MonthDayYear
Patients Email*
example@example.com

Appointment Details
Date*

MonthDayYear
Date
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.

7:00 AM to 10:00 AM (Recommended if fasting is required)10:30 AM to 12:30 PM1:00 PM to 3:30 PM
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

To use insurance, a lab order from your physician is required. Travel fee is NOT covered by insurance.
Choose one option.*

I have a lab order from my physicianI don’t have a lab orderGenova Diagnostic Kit
Upload Lab Order from your physician*

Cancelof
Payment Method

We accept Medicare and ALL PPO
How do you intend to pay for your bloodwork?*

PPO InsuranceMedicareSelf Pay
Insurance Provider*
Policy Number*
Medicare ID*
Upload Front of Insurance Card*
Upload Back of Insurance Card*
Upload Government-issued ID*
Acknowledgement*

An invoice will be sent to you via email for the travel fee. To confirm your appointment, please ensure the invoice is paid at least 48 hours before your appointment. In the event of non-payment, Lions Laboratory will make an attempt to reach out to you. If no communication is established, your appointment will be cancelled.
Acknowledgement*

An invoice will be sent to you via email which includes the price of tests indicated on your lab order and the travel fee. To confirm your appointment, please ensure the invoice is paid at least 48 hours before your appointment. In the event of non-payment, Lions Laboratory will make an attempt to reach out to you. If no communication is established, your appointment will be cancelled.

Concierge Mobile Phlebotomy Request