Mobile Blood Draw Client Intake Form

Mobile Blood Draw Client Intake Form

Greater Works Wellness
Please Read Before SubmittingThank you for choosing Greater Works Wellness for your specimen collection needs. Please review the steps below before completing this form:

Step 1: Complete this form in full and upload a copy of your laboratory order (requisition).
Step 2: After review of your lab order, a payment link and scheduling link will be sent to you via phone or email.
Step 3: Your appointment is confirmed once payment is received and you select the appointment date.

Cancellation Policy:
Clients may cancel up to 24 hours prior to their scheduled appointment to receive a full refund. Cancellations made less than 24 hours before the appointment will receive a 50% refund.

For questions please call (832) 404-3928 or email info@gwwhealth.com.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Do you consent to receiving text messages regarding your upcoming appointment?*

YesI'd rather not
Your address or the address of where your blood collection service will take place. Please note that blood collection services must be completed indoors. *

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Please indicate the setting where your blood will be collected. This information allows us to properly prepare for your appointment, ensure appropriate safety measures are in place, and provide the highest level of care for both our clients and staff.*

My residenceMy place of employment or workA medical facilityOther
Please select the laboratory where you wish your samples dropped off for testing. *
What if your preferred appointment date?*
Do you have any of the following medical conditions?*

Bleeding disorders (e.g., hemophilia)Blood thinners (anticoagulant medication)Fainting or dizziness or vomiting with blood drawsDiabetesNeedle phobiaNone of the aboveOther
Do you require special accommodations? (Please explain)
Preferred Time Window (Morning / Afternoon / Evening) for your appointment? Select all that apply.*

Early Morning (6AM-8AM)Mid Morning (9AM-11AM)Early Afternoon (12PM-1PM)Afternoon (1PM-3PM)I do not have a preference
Acknowledgment: I understand that my appointment is not confirmed until payment is received. I understand and agree to the 24-hour cancellation policy. I understand that I will only receive 50% of my payment if I cancel less than 24 hours of my scheduled appointmentI understand that Greater Works Wellness provides specimen collection services only. Laboratory testing and results are processed and reported by the designated reference laboratory including Greater Works Wellness partnered reference laboratory.*

I have read and acknowledged the statements above.
Upload Your Lab Order (Requisition)(PDF or clear photo required before scheduling)*

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