Name
First Name
Last Name
DOB
-
Month
-
Day
Year
Date
Serum Percentage
20%
30%
33%
50%
80%
Other
Number of Blood Vials to Draw for Standard 15 Bottles
5 (20%,30%,33%)
8 (50%)
10 (80%)
Other
Appointment
Phlebotomist
Please Select
Jordany: Cell# (404)-719-3318
Anita: Cell# (678)-353-8528
Shabana: Cell# (770)-601-7053
Location of Blood Draw
Facility
Home
Price of Blood Draw
Number of Bottles to Make if Greater than 15 Bottles
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