Lab Submission
Welcome to Greater Works Wellness! Please use this secure form to submit your lab order and request mobile phlebotomy or diagnostic services. Be sure to complete all required fields to help us provide timely and accurate care.
đź“ŚÂ Instructions:
Upload a clear copy of your lab form or physician’s order. Ensure your contact information is accurate for appointment scheduling. If you are submitting on behalf of someone else, please include their details as the patient. A member of our team will contact you within 24 hours to confirm your appointment.
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Patient Full Name
*
First Name
Last Name
Patient's Date of Birth
*
 -
Month
 -
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Preferred Appointment Date
 -
Month
 -
Day
Year
Date
Prefered Appointment Time
AM
PM
Upload Lab Form or Physician's Order
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
How did you hear about our services?
Referral
Website
Social Media
Type option 4
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Notes
Submit
Should be Empty: