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REQUEST FOR A PAPER

📅 Book a Blood Draw Appointment

Complete the form below and one of our team members will follow up with you shortly.

Patient Information

First Name *

Last Name *

Middle Initial

Sex at Birth *

Date of Birth (MM/DD/YYYY) *

Mobile Phone *

Email Address * Street Address *

City *

State *

ZIP Code *

Doctor's Order Do you have a doctor's order? *

Upload Doctor's Order Accepted formats: PDF, JPG, PNG

Lab Test Requisition

Please select the tests you need:

Test Panels

Anemia Profile (P20) Arthritis Profile (31) B12 + Folate Deficiency (39) Basic Metabolic Profile (11) Comprehensive Metabolic (12) Diabetic Profile (24) Electrolytes (10) Hepatic Function (27) Hepatitis Panel (2254) Lipid Profile (38)

Common Individual Tests

CBC with Differential & Platelets Cholesterol Triglycerides HDL Cholesterol Glucose Fasting Hemoglobin A1C TSH (Thyroid) PSA Total Vitamin B12 Vitamin D-25 Hydroxy

Hormone Tests

Testosterone Total FSH LH Progesterone Estradiol Prolactin

Cancer Markers

CA 125 CA 15.3 CA 19-9 CEA AFP Tumor Marker

Additional Tests

Other Tests (please specify):

Fasting Status

Diagnosis Information ICD-10 Code (if known) Clinical Diagnosis/Reason for Testing *

Insurance Information

Primary Insurance Provider

Member ID

Secondary Insurance (if applicable)

Secondary Member ID

Collection Preferences

Collection Type *

Priority *

Preferred Appointment Time Special Instructions

Consent & Agreement I consent to Micron Labs On Demand collecting and testing my sample as described above. I authorize billing my insurance and understand I am responsible for any charges not covered by insurance.

S.3 Geography MID 2 2025 Kiyala High School

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