My One Medical Source - Lab Survey Question Title * 1. Do you have a need for greater access to Phlebotomy? Yes No OK Question Title * 2. Lab Name OK Question Title * 3. Is your need: (Check all that apply) National Regional Local: If local, please provide city: OK Question Title * 4. What is your current solution for Phlebotomy collections? (Choose all that Apply) Have our own Patient Service Centers Have our own Phlebotomists Provide In-Office-Phlebotomy Use Medical Staffing Company(s) Use Mobile Phlebotomy Use Local Brick and Mortar Solution(s) Other (please specify) OK Question Title * 5. Where do you need access to Phlebotomy the most? OK Question Title * 6. What is your greatest need when it comes to access to Phlebotomy? (Check all that apply) Ability to draw panels Ability to perform individual tests Ability to collect specimens for provided "kits" Ability to have samples properly processed, handled and shipped Other (please specify) OK Question Title * 7. Do you provide Patients with "KITS" with all the instructions and supplies? Yes No Sometimes OK Question Title * 8. Typical Collection consists of (Check all that apply): Standard Tubes Transfer Tubes Special Tubes Special processing/handling requirements Special shipping requirements Freezer brick Dry ice Other (please specify) OK Question Title * 9. Typical Collection Requires: One Collection Tube Between 1 and 3 Tubes Between 4 and 6 Tubes 7 or More Tubes Other (please specify) OK Question Title * 10. Do you currently have an option for a Patient to Pay for the phlebotomy collection? Yes No OK Question Title * 11. What is the amount that you (LAB) or the patient are willing to pay for your phlebotomy collection? (Choose 1) $15 per requisition $20 per requisition $25 per requisition $30 per requisition $35 per requisition Other (please specify) OK Question Title * 12. Do you currently offer or plan to offer a Direct to Consumer or Direct Access Testing Solution? Yes No OK Question Title * 13. How many sales representatives do you currently have? OK Question Title * 14. MOMS is building a national network of Medical Access Points (MAPS) that will serve as a brick and mortar network of collection sites. Would you like to see a demo of the MOMS Platform? Yes No OK Question Title * 15. If YES, please provide contact Information: Name Company Title Email Address Phone Number OK DONE
