Pure Flow Diagnostics Facility Partnership Request Form
Thank you for your interest in partnering with PureFlow Diagnostics for professional mobile phlebotomy and specimen collection services. Please complete the form below and a representative will contact you within 24–48 business hours to discuss your facility’s service needs.
SECTION 1: FACILITY INFORMATION
Primary Contact Name
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Email
example@example.com
Facility Address
SECTION 2: SERVICE REQUEST
Type of Service Needed
Please Select
Routine Blood Draws
STAT / Urgent Draws
Specimen Pickup
Recurring Scheduled Visits
Other
Estimated Number of Patients per Visit
Visit Frequency
One-time service
Weekly
Bi-Weekly
Monthly
As needed
SECTION 3: SCHEDULING REQUESTS
Preferred Days for Service
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred Time Window
Please Select
Morning (8am-12pm)
Afternoon (12pm-4pm)
Evening (4pm-7pm)
Flexible/Anytime
Urgency Level
Routine (Standard Scheduling)
Urgent (Within 24-48 Hours)
STAT (Same Day/ASAP)
SECTION 4: BILLING & PAYMENT
Billing Responsibility
Facility Pays (Invoice Required)
Patient Self-Pay
Third-Party Billing Agreement
Needs Further Discussion
Payment Terms Agreement
*
I understand that payment terms will be confirmed prior to service and agree to billing policies.
Billing Contact Email (if different from above)
Billing Notes / Special Instructions
SECTION 5: CONSENT & ACKNOWLEDGMENT
HIPAA & Confidentiality Acknowledgment
*
I understand that PureFlow Diagnostics will maintain confidentiality and protect all patient and facility information in accordance with applicable privacy standards.
Service Policy Agreement
*
I understand that appointment scheduling, cancellations, and payment terms will be confirmed prior to service.
Authorized Representative Name
Title / Position
Authorized Signature
*
Submit Facility Request
Submit Facility Request
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