Patient Intake Form Please complete all of the following as accurately as possible: Your Name: Birthdate: Your Phone Number: Your Email Address: Address: City: Zip: Test Request?: Appointment Date: Time: Preferred Lab: Fedex: UPS: Special Request: Credit Card #: Exp: csv: How did you here about us?: This is a Premiere Concierge service, If scheduled service is cancelled at least 24 hours prior to the appointment, No charge. If scheduled service is cancelled after 24 hours of the appointment, the customer/patient will be charged 50% of the full cost of the service. if the customer/patient is not at the scheduled location, or the appointment is cancelled within 2 hour or less of the appointment time, the customer/patient will be charged full cost of the service.