Lab on Demand Appointment Request Form

Lab on Demand Request Form

Cash, card or check accepted as payment for lab charges and required at the time of service. Insurance is not billed for these services. We apologize for the inconvenience.
Client's Name*

First NameLast Name
Legal Guardian (if applicable)

First NameLast Name
Date of Birth*

MonthDayYear
Date
Contact Number*
Please enter a valid phone number.
Email Address
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What date and time work best for you?*
What labs would you like drawn?*

Health Fair Profile (CMP, Lipid, TSH, CBC) $45 (8 hour fast required)TSH High Sensitivity $30Thyroid Panel (Includes TSH) $55PSA $35CBC $26Lipid Panel $20 (8 hour fast required)Hemoglobin A1C $30Vitamin D $60Hepatitis C Antibody $60Hepatitis B Surface Antigen $50Varicella Titer $44Uric Acid $24Iron $23MMR Panel $55Comp. Metabolic Panel (CMP) $30 (8 hour fast required)Other
If you chose other, please explain:
By completing this form you are scheduling an appointment with the Dawson County Health Department, located at 207 West Bell Street in Glendive, MT. If there are questions regarding your submission you may be contacted by a DCHD staff member on the phone number provided. If you have any questions or need to cancel or change this appointment please call us at (406)377-5213.
Date

MonthDayYear
Date
Should be Empty:

Lab on Demand Request Form