First Name Last Name Address Date of Birth Gender M F City Last four digits Social Security Number Patient State Zip Code Phone Information (Optional) Email Address: Date of application: Payment Method: Payments are accepted through Square and personal check. A link will be sent to your email for payment upon receipt of this order form. Please indicate your method of payment. Check Enclosed Square payment information For square payments, please confirm your email address: __________________________________ Patient signature_________________________________________________ Payment I have requested discount lab services from the PALS organization. I understand that I am responsible for Physician follow-up, treatment plan, medications, and further testing. I also understand that testing is confidential and no information provided would make it possible for identification will be included in any reports. Patient consent Patient Signature_____________________________________________________ ___________________________________________________________________ Test Code Test name Fee Lab work
Patient Information First Name Last Name Address Date of Birth Gender M F City Last four digits Social Security Number State Zip Code Phone (Optional) Email Address: Date of application: Payment information Payment Method: Payments are accepted through Square and personal check. A link will be sent to your email for payment upon receipt of this order form. Please indicate your method of payment. Check Enclosed Square payment For square payments, please confirm your email address: __________________________________ Patient signature_________________________________________________ Patient consent I have requested discount lab services from the PALS organization. I understand that I am responsible for Physician follow-up, treatment plan, medications, and further testing. I also understand that testing is confidential and no information provided would make it possible for identification will be included in any reports. Patient Signature_____________________________________________________ ___________________________________________________________________ Lab work Test Code Test name Fee
PALS-Application-2018-1.docx