DISCOUNT BLOOD TESTING - ORDER FORM

INSTRUCTIONS:
•	Please complete every line on this form that applies, sign and FAX to DiscountBloodTesting.com. 
•	Upon receipt of this fully completed Order Form and Release, you will be mailed a voucher which you must take to the Discount Blood Testing Clinic near to you on test day.
•	You will be paying online at the DiscountBloodTesting.com website by Credit Card.
•	If you wish to have a copy faxed to you, provide your fax number: (____)________________.
•	If you wish to have a copy faxed to your doctor, provide a fax number: (____)_______________.

NOTE: Self-diagnosis is not recommended. Discount Health Screening and Discount Blood Testing are parts of a quality and useful diagnosis and they are not intended to be a substitute for consultation with a qualified medical professional. 

ORDER DATE: ______/______/________

AGE: _______   DATE OF BIRTH: ______/______/________

THIS TEST ORDER IS FOR: (  ) Male   (  ) Female

_______________________________, _________________________
Last Name                                             First Name

_________________________________, ______________________, _____, _______
Address                                                     City                                     State    Zip

(____)________________, (____)_________________, __________________________
Home Phone                       Other Phone                        Email Address

Test Order                                                            Cost
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2

3

4

5

6

TOTAL COST

Payment: by telephone or online

Signature: ________________________________