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care@curisdiagnosticsolutions.com

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Mobile Phlebotomy Support Services Request Form

Please complete the form below to request mobile phlebotomy or laboratory support services. A Curis Diagnostic Solutions representative will contact you within 24–48 hours to confirm details and scheduling.

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Client Information

Client / Facility Name

Contact Person Name & Title

Phone Number

Email Address

Service Address (Where Phlebotomy Is Needed)

Client Type

Medical Facility Laboratory Nursing Home / Assisted Living Corporate / Employer Home Health Agency Private Pay / Individual Other

Services Requested

What Services Are Needed?

Routine Blood Draws STAT / Urgent Blood Draws Standing Orders (Recurring Patients) Specimen Pick-Up & Delivery COVID / Flu / RSV Swabs Mobile Health Screenings Corporate Wellness Blood Panels PRN Phlebotomy Coverage (Staff Shortages) Long-Term Contracted Phlebotomy Support Weekend / Evening Coverage Other Services Needed

Volume & Scheduling

Estimated Number of Patients / Draws

Requested Start Date

Frequency of Service Needed

One-Time Service As Needed (PRN) Daily Weekly Monthly Ongoing / Contracted

Preferred Service Time

Morning Afternoon Evening Overnight Weekend Flexible

Patient / Population Details

Type of Patients Served

Adult Pediatric Geriatric Special Needs Bed-Bound / Non-Ambulatory Homebound High-Risk / Immunocompromised

Do you require phlebotomists with specialized experience?

Yes No

Specimen Handling

Where should specimens be delivered?

Quest Diagnostics LabCorp In-House Laboratory Reference Laboratory

Do you require specimen processing (centrifuging)?

Yes No

Billing Information

Payment Type

Facility Billing Corporate Billing Insurance-Based Private Pay / Self-Pay

Preferred Billing Method

Invoice Per Visit Weekly Billing Monthly Billing Contracted Rate

Billing Contact Name

Billing Contact Email

Additional Notes

Additional Instructions or Requests

Authorization

Authorized Representative Name

Title

Signature

Date

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Providing trusted, mobile diagnostic services—from phlebotomy and specimen transport to DNA and drug testing—delivered with care, precision, and confidentiality. Wherever you are, we’re here to support your health journey.

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Curis Diagnostic Solutions, LLC
618-207-4568
care@CurisDiagnosticSolutions.com

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