Patient Intake | Onsite Phlebotomy Solutions

Patient intake: complete one form per patient. Upload only the lab order needed for your visit. Submitting this form does not confirm an appointment. For scheduling help, call (909) 554-3386.

Patient first name

Patient last name

Contact email

Contact phone number

Appointment address (street, unit, city, state, ZIP)

Patient date of birth

Month

Day

Year

Lab order (document or clear photo)

Open or download the Patient Consent Form (PDF)

Please review the sections that apply to your appointment. The consent form must be completed and signed before services are provided. Contact us at (909) 554-3386 if you have questions.