Peak Performance Medical Lab - Request Service Form

Contact Information

Full Name *

Company / Organization

Phone *

Email *

Preferred Method of Contact: *

Service Type ( Choose One) *

If Occupational Testing is Selected

Testing Category *

Mobile / On-Site ? *

Number of Individuals (Estimate) *

Requested Date *

After-Hours / Weekend Needed ? *

Address

Street Address ( Mobile Testing Only ) *

City

State

Postal code

Additional Notes ( Do not include personal health information )

If Medical Courier is Selected

Delivery Priority *

Item Type *

Temperature Control Needed? *

Chain of Custody Required? *

Pickup Address *

Delivery Address *

Additional Notes ( Do not include personal health information )

Captcha

I confirm that I am not submitting any protected health information (PHI). I understand that Peak Performance Medical Lab will contact me to confirm details.