Mobile Blood Draw Request Form

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We require the lab order prior to scheduling. Are you able to send this to us in any one of the methods below?

E-Mail: info@ptchoice.com
Text: 602-923-0605
My doctor sent you the order directly
Fax: 602-314-5048

Patient Name

First

Last

Note: If patient is a minor under 18 years of age a legal parent or gardian must be present and consent for draw.

Patient Phone Number

We will call this number to confirm an appointment time.

Consent to Text Mesage

Yes, I consent to text messages
No, I do not want text messages

I consent to receive SMS from Patient's Choice Lab. Reply STOP to opt-out; Reply HELP for support; Message & data rates may apply; Messaging frequency may vary. Visit https:// ptchoice.com/privacy-statement/ to see our privacy policy and our Terms of Service.

Patient Contact Email:

Do you want to bill insurance for the lab testing?

What get are

What is the address for the appointment?

Include appartment numbers, lot numbers, building numbers, etc.

Is there a gate code or any special instructions to get to you?

When are you looking to schedule a mobile appointment?

Please list the date(s) and time window you're available. Our team will reach out to finalize your appointment based on availability. Appointments are first come first serve. Note: Our appointments take approximately 15 minutes to complete.

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Mobile Blood Draw Request Form