Precision Mobile Draw Appointment Request
Please complete this form and upload your laboratory order, Precision Mobile Draw will contact you to confirm.
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Ordering Physician
Upload Lab Order
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Preferred Appointment Date
*
-
Month
-
Day
Year
Date
Preferred Appointment Time
Relationship to Patient
*
Self
Parent
Legal Guardian
Other
Consent & Authorization : I certify that i am the patient or the patient's parent/legal gaurdian and authorize Precision Mobile to perform specimen collection as ordered by my healthcare provider. I understand that blood collection may involve risks including bruising, bleeding, discomfort, dizziness, or fainting. I understand that Precision Mobile does not diagnose medical conditions or interpret laboratory results. I consent to be contacted regarding scheduling, appointments, and services.
*
I Agree
I Do Not Agree
Special Instructions
Financial Responsibility : I understand that the mobile collection fee is separate from laboratory testing fees and I am responsible for payment of the mobile service fee.
*
I Agree
I Do Not Agree
Signature
*
Continue
Continue
Should be Empty: