Request a Mobile Blood Draw or Specimen Collection
Share your contact details, preferred appointment time, and any lab order information so we can schedule your mobile blood draw or specimen collection.
Patient Contact Info
Full Legal Name (as it appears on your doctor's order)
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Mobile Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Appointment Details & Location
Full Service Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Appointment Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Time Window
*
Early Morning (6:00 AM – 9:00 AM) — Recommended for fasting tests
Mid-Morning (9:00 AM – 12:00 PM)
Afternoon (12:00 PM – 4:00 PM)
Lab Order & Test Verification
Do you have a copy of your lab order or requisition form?
*
Yes, I will upload it below
No, my doctor is sending it directly to First Draw
No, this is a self-pay or specialty kit that does not require a doctor’s order
Upload lab order or requisition form
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Does your test require fasting?
*
Yes
No
I’m not sure
Safety & Patient Comfort
Are there any specific notes for our phlebotomist? (Select all that apply)
*
I have an extreme fear of needles / severe anxiety
I am a hard stick / have difficult veins
I experience dizziness or fainting during blood draws
Gate code or specific parking instructions at my address
Additional details or instructions
Acknowledgment & Consent
Acknowledgment of Service Provider and Lab Order Readiness
*
I understand First Draw Mobile Service is an independent collection provider and I agree to have a valid doctor's order ready or submitted prior to my appointment time
Acknowledgment of Mobile Convenience/Service Fee
*
I understand a mobile convenience/service fee applies to home or office visits
Save
Submit Request
Should be Empty: