top of page

Physicians can place orders directly through our secure online portal or via fax.

WE ARE MOBILE WE COME TO YOU!

On-site 7am–7pm | Emergency support 24/7."

I&K Urgent Labs LLC

MOBILE PHLEBOTOMIST

HOME
LEGAL NOTICE
ABOUT US
CAREERS
CLIENT PORTAL
CONTACT
PHYSICIAN PORTAL
- PHYSICIAN ORDER FORM
Gift Card
More

Use tab to navigate through the menu items.

I&K Urg Laboratory Requisition Form

Laboratory Requisition Form

First name*

Last name*

Email*

Phone

Date of Birth

Month

Day

Year

Sex

Female

Male

Other

SSN

Ethnicity/Race

Height

Weight

Marital Status

Single

Married

Divorced

Separated

Widowed

Spouse Name

Spouse Phone

Referring Physician Information:

Physician Name

Clinic/Hospital

Specialty

Clinic/Hospital Address

Phone

Email

Physician Order upload

Insurance Information

Insurance Provider

Policy Number

Group Number

Insurance upload

Test Information

Date of Order

Month

Day

Year

Specific Tests Ordered

Pediatric Labs

Routine Labs

Stat Labs

Specimen pick up/drop off

Drug Testing

DNA Testing

Clinical History/Reason for Testing

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Book Now

Tel: (251) 404-7763

bottom of page