*1.First and Last Name(Required.)

*2.Email Address(Required.)

*3.Phone Number(Required.)

*4.Date of Birth(Required.)

5.Which labs do you want drawn?

CBC w/diff & Ferritin: $25

Vitamin D: $25

Lipid Panel: $10

Comprehensive Metabolic Panel: $10

Hemoglobin A1C: $25

Thyroid Panel: $125 (Incl. T3 Uptake, T4 Total, Free T4 Index, TSH, Reverse T3, Thyroglobulin Antibodies, Thyroid Peroxidase)

All of the Above: $200

Other (please specify)

*6.What is your preferred time?(Required.)

9 a.m.

9:15 a.m.

9:30 a.m.

9:45 a.m.

10 a.m.

10:15 a.m.

10:30 a.m.

10:45 a.m.

11 a.m.

11:15 a.m.

11:30 a.m.

11:45 a.m.