Home Visit Appointment

Identifying Information

First Name

Phone Number

Last Name

Birthday

Steet Address

City

State

County

Zip Code

Doctor's Name

Requesting Laboratory

Have you tested positive for COVID-19?

Yes

If your appointment has already been scheduled indicate the date and time.

I confirm that the information given in this form is true

I understand that I am responsible to pay $100 cancellation fee if I do not give 24 hour notice to cancel my appointment

I understand that I am responsible to pay the $100 non compliance fee IF a pet is present when the phlebotomist arrives

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Your Signature