Patient Appointment form

Concierge Services
Please Select the Desired Service(s) Below:
prevnext( X )
Specialty Test Kit/Igenix/Genova/NutraEval/Alletess/Galaxy etc...Shipping and Handling: $25 Processing Fee: $12.50 Mileage: $12.50
$50.00 Quantity



Stat/Same Day Mobile PhlebotomyShipping and Handling: $150 Processing Fee: $50 Mileage: $25
$225.00 Quantity



Multiple Requisition Forms
$25.00 Quantity



Peekaboo Gender Reveal Test
$90.00 Quantity



DDC Paternity, Infidelity, Immigration TestingShipping and Handling: $50 Processing Fee: $50 Mileage: $25
$125.00 Quantity



Basic Blood DrawStandard
$75.00



Total

$0.00
Name

First NameLast Name
E-mail
example@example.com
Contact Number
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

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