Lab Order E-Consult Request

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I understand the information provided above will be used to establish an electronic health record in a secure portal and I will receive an invitation for the portal.

I am requesting the following service:

Order/Interpretation: Standard Panel, draw center of choice. Labs not included.$125

Order/Interpretation: Premium Panel, draw center of choice. Labs not included.$125

Self-Pay labs through RUPA/LabCorp. Interpretation fee $125 + cost of labs/fees.$125

Standard Lab Panel includes: CBC, ferritin, glucose, insulin, TSH, FT4, FT3, TPO/TGA antibodies and prolactin.

Premium Lab Panel includes: all labs in in Standard Lab Panel plus Vit D, Vit B12/folate, magnesium and zinc.

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