DIY Lab Tests for Non-Clients
Self-Pay Labs at Affordable Prices: Please read ALL of the below information carefully. Lab orders may be taken to *any* LabCorp location. This is for self-chosen labs only and will not include medical interpretation or recommendations. In other words, a healthcare provider at this clinic will not review or interpret your lab result and no medical advice or recommendations will be provided based on these results. The Venipuncture fee (blood draw fee) of $11 is required and pre-selected below. Please read the following information below in full, including the RELEASE FORM, for service details. If you do not see a lab listed that you are interested in, please contact our clinic. Once your information is submitted, the fee is non-refundable.
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Venipuncture fee *** REQUIRED ***
This is a required fee from the lab company for performing the lab draw.
$
11.00
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Testosterone Total, Free, and SHBG
Enter description
$
75.00
Quantity
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10
FSH & LH
fertility hormones
$
40.00
Quantity
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10
SHBG (Sex Hormone Binding Globulin)
Synonym: Free Androgen Index (FAI)
$
40.00
Quantity
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Estradiol
Enter description
$
20.00
Quantity
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Lipid Panel
HDL, LDL, Total Cholesterol, Triglycerides, VLDL - Do not eat or drink after midnight the night prior for accurate results. (Can have water.)
$
14.00
Quantity
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Vitamin D level
Vitamin D, 25-OH, Total
$
40.00
Quantity
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10
Vitamin B12 level
$
20.00
Quantity
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10
CBC
Complete Blood Count
$
8.00
Quantity
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10
CMP
Comprehensive Metabolic Panel
$
15.00
Quantity
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10
PSA, Free & Total
Prostate Specific Antigen
$
20.00
Quantity
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10
TSH
Thyroid Stimulating Hormone
$
48.00
Quantity
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10
TPO Antibodies
$
35.00
Quantity
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Cortisol
Morning lab draw: 8am needed for accuracy.
$
12.00
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T3, Free
$
20.00
Quantity
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10
T4, Total
$
20.00
Quantity
1
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Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
RELEASE FORM- Please READ in full.
Purpose of the Test: This form is to acknowledge that you, the client, are requesting laboratory blood testing. Scope of Service: The clinic will order your requested blood work once submitted and will facilitate the collection and processing of your blood sample to be completed at any LabCorp location (anywhere). You will be provided with a copy of your lab results once they are available via e-mail. We do not accept insurance. These labs are "self-pay" only and a "super-bill" will not be provided for insurance companies. Important Information: Lab Requisition: After payment is received, you will receive a lab requisition form by the next business day. This is your lab orders. Please print a copy of the lab requisition form and take it to any LabCorp location, anywhere, for your blood draw. You can also present it from your phone, but a printed copy is preferred. You can go as a walk-in client, as no appointment there is required. Lab Result Timing: Lab results are usually available within 1 business day. If you do not receive a copy of your results within 2 days, please contact our clinic. No Medical Interpretation or Recommendations: A healthcare provider at this clinic will NOT review or interpret your lab results. No medical advice or recommendations will be provided based on these results. Follow-Up: It is your responsibility to consult with a primary care provider or a specialist for interpretation of your lab results and any necessary follow-up care. Confidentiality: Your lab results will only be shared with you at the e-mail address you provide. Acknowledgment and Consent: By signing this form, you acknowledge and agree to the following: - You understand the scope of the service provided by the clinic as written above. - You understand that Powerhouse Men's Clinic LLC will not provide medical advice or treatment based on the lab results. - You agree to consult with a primary care provider or appropriate healthcare professional for interpretation and guidance regarding your lab results. - No Refund Policy: Once this form is submitted, refunds are unavailable. - You release Powerhouse Men's Clinic LLC, its providers, and affiliates from any liability related to the lab results.
Signature: By signing here, I acknowledge I have read and understand the release form above in full.
*
Legal Name
*
First Name
Last Name
Date & Time
Biological Sex:
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
E-mail for Results
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
Should be Empty: