Please complete and submit the following information only after submitting payment for any lab requests. This information will be used to create and track your lab requisition and results. Your lab requisition will be sent to the email you provide. If you do not receive your requisition within 30 minutes, please call or text 866-634-5377.

 

*For DISCOUNT CODE:  Once your form is submitted, check your email for a PayPal Invoice. 

Patient Information
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