SECTION 1: FACILITY INFORMATION
🏥 Provider & Facility Partnership Request
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.
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
Corporate Wellness Events
Employee Health Screenings
Other
Estimated Number of Patients Per Visit
1-5
6-10
11-25
26-50
50+
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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