Phlebotomy Direct – Powered by Coronainfo LLC

Fast. Convenient. Professional.
Your choice for mobile blood draws!
Currently serving patients in the following counties:
Los Angeles, Orange, San Diego, Ventura, Riverside, San Bernardino County, and Bakersfield.

PATIENT REGISTRATION FORM

Please enter the required information on each tab in it’s entirety.

Last Name: *

First Name: *

Middle Name:

DOB:*

(MM/DD/YYYY)

Gender:*

Email:*

Phone Number:*

Street Address:*

Street Address 2:

City:*

State:*

Postal Code:*

Insurance Name:

Insurance Member ID:

Insurance Group ID:

Upload Insurance Card Front:

Upload Insurance Card Back:

Upload Government ID:

Please Enter Lab Order Information

Ordering Physician:

If your Ordering Physician is not listed, please type their name here (Last Name, First Name):

Laboratory Name:

If your Laboratory is not listed, please type their name here:

Please Upload an Image of the Lab Order:

Please enter the required information on each tab in it's entirety.