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Request Summary

Requested Service	Fees
QuantiFERON-TB Gold Plus Test	$168.30
Doctor's Lab Order (included)	$0.00
Lab Collection Fees (included)	$0.00
Total Fees:	$168.30

Complete the form below to submit your request. All fields are required.

1. Choose Testing Location

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Your Selected Lab

2. Patient Demographic Information

First Name

Last Name

Confirm Email

Sex

Female

Male

Birth Date

Phone

Address

City

State

Zip Code

3. Patient Health Information

Past Medical Problems (e.g. Asthma - if none, type "none")

Current Medications (if none, type "none")

Known Allergies (if none, type "none")

Are you pregnant?

Are you breastfeeding?

Yes

Reason for Lab Testing (detailed is better)

4. Confirm Request and Agree to Terms

Name:
Sex:
Birth Date:
Age:
Service:	QuantiFERON-TB Gold Plus Test

Total Fees: $168.30

Total fees include the lab order, all lab fees, and a copy of the results. By clicking "Submit Request", you indicate that you, as the patient or legal guardian of the patient, agree:

to follow up with my regular medical provider for ongoing care;
to the best of my knowledge, all information submitted is accurate;
to the Terms of Service and Consent to Telehealth.

Name:
Birth Date:
Age:
Sex:
Email:
Phone:
Address:
Request:
Lab Location:

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