Patient Intake

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.

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