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Therapeutic Phlebotomy Request Form

Patient Information
Please enter the patient's date of birth in MM/DD/YYYY format.
Please enter an email address where we can contact the patient.
Please enter a phone number where we can contact the patient.
Patient Mailing Address
Patient Diagnosis and Phlebotomy Instructions



(HIV, HCV, HBV, etc.)


(Optional) Enter the number of collections to collect before holding. Request will expire once the number of collections entered below are filled. Please enter a numeric value.
Minimum Hemoglobin for Phlebotomy
Please select one.
Ordering Provider Information and Acknowledgement
(if applicable)
Please enter today's date in MM/DD/YYYY format.
By checking this box, the treating provider confirms they are authorized to practice in the state of Texas, and the patient will be able to tolerate therapeutic phlebotomy procedure(s). Furthermore, the patient does not have any medical contraindications for blood draws, and the risks and benefits of therapeutic phlebotomies have been discussed with the patient.
The treating provider acknowledges that checking this box is the legally binding equivalent of their handwritten signature.
Please check the box to verify that you are human!
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