Pure Flow Diagnostics
Patient Intake Form
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name & Phone Number
Provider Information
Provider Name
Provider Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Upload Physician/Lab Order
*
Browse Files
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Appointment Information
Service Area
*
Please Select
Austin
Houston
Appointment Location Type
Please Select
Home
Assisted Living Facility
Clinic
Corporate Wellness
Other
Requested Appointment Date
-
Month
-
Day
Year
Date
Requested Time Window
Please Select
Morning
Afternoon
Evening
Collection Information
Is fasting required?
Yes
No
Unsure
Mobility Concerns?
Yes
No
Pediatric Patient
Yes
No
History of Difficult Blood Draw?
Yes
No
Acknowledgment
Acknowledgment & Consent
*
I acknowledge that provider orders are required before specimen collection services can be performed. I understand that mobile service fees may apply, and that PureFlow Diagnostics provides specimen collection services only and does not interpret laboratory results.
Patient Signature
*
Policies & Acknowledgments
HIPAA & Privacy Acknowledgment
*
I acknowledge that PureFlow Diagnostics will maintain the confidentiality of my personal and health information in accordance with applicable privacy standards.
Cancellation & No-Show Policy
*
I understand that cancellations made less than 24 hours before the appointment will be charged 50% of the service fee and no-shows will be charged 100% of the service fee.
Payment Authorization Agreement
*
I understand that a valid payment method is required to secure my appointment and may be charged according to the cancellation policy.
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