2003 Rickety Lane, Suite D, Tyler TX 75703Mon–Fri 7am–5pm · Sat by appointment

903-497-1459Mobile Phlebotomy · CLIA-Waived Testing

A Lonestar Verify Diagnostic Lab Company

Book Your Appointment

Schedule a mobile blood draw at your location or order lab tests at a nearby lab — all in one place.

CLIA-Waived Certified Clinic 4 Years Experience HIPAA Compliant Same-Day & Next-Day Available

Your information is kept private and HIPAA-compliant.

How would you like to be served? *

Personal Information

Full Name *

Date of Birth *

Phone Number *

Email Address *

Add an additional person who needs services (+$25.00)

Appointment Details

Preferred Date *

Preferred Time *

Fasting? *

Doctor's Name (if applicable)

Doctor's Phone (if applicable)

Service Location

Where should we come?

Street Address *

City *

State *

Zip *

Gate Code / Access Instructions

Insurance & Billing

Do you have a lab order from your doctor?

Yes — I will upload it below No — I need to order my own tests Not sure

Upload Lab Order (PDF, JPG, PNG)

Insurance Company

Member ID

Group Number

Policy Holder Name (if different)

Insurance Card — Front

Insurance Card — Back

Payment

Order Summary

Service—

Mobile Travel Fee$35.00

Total$35.00

Your card is charged after your appointment is confirmed. Enter your card details below.

Credit/Debit Card HSA/FSA Card Money Order (at time of service) Invoice (facilities/employers only)

Cardholder Name *

Card Number *

Expiry *

CVV *

We do not store your full card number.

Full refund if canceled 24+ hours in advance. No refund for same-day cancellations. Lab tests billed separately to insurance through Quest/LabCorp.

Additional Notes

Anything else we should know?

Notes / Special Instructions

Digital Waiver & Consent

CONSENT FOR MOBILE PHLEBOTOMY SERVICES AND LABORATORY TESTING

1. CONSENT TO TREATMENT
I consent to the collection of blood and/or other specimens by a certified phlebotomist from MyChartLabs. I understand the procedure may involve venipuncture (needle insertion) and/or capillary puncture (finger stick).

2. HIPAA AUTHORIZATION
I authorize MyChartLabs to collect, use, and disclose my protected health information (PHI) for treatment, payment, and healthcare operations, in compliance with HIPAA regulations.

3. FINANCIAL RESPONSIBILITY
I acknowledge I am financially responsible for all services rendered. I understand my card will be authorized at booking and charged after my appointment is marked complete. Lab tests are self-pay (cash pay only) and not billable to insurance.

4. CANCELLATION POLICY
Full refund if canceled 24+ hours before the appointment. No refund for same-day cancellations.

5. RISKS AND COMPLICATIONS
I understand blood draws may involve minor risks including bruising, discomfort, dizziness, or infection at the puncture site. I acknowledge I have been informed of these risks.

6. RELEASE OF LIABILITY
I release MyChartLabs, its employees, and contractors from liability arising from complications related to the blood draw procedure, except in cases of gross negligence or willful misconduct.

7. ACCURACY OF INFORMATION
I certify that all information provided (name, date of birth, contact details, insurance) is accurate and complete to the best of my knowledge.

8. ELECTRONIC SIGNATURE
I understand that by signing below electronically, this signature has the same legal effect as a handwritten signature.

By signing below, I acknowledge I have read, understood, and agree to all terms outlined in this consent form.

Electronic Signature *

Sign here using your mouse or finger

Print Full Legal Name *

Date

I have read and agree to the terms of this consent form. My electronic signature above represents my legally binding consent.

Consent & Submit

I agree to the Terms of Service and Privacy Policy I consent to HIPAA-compliant handling of my health information I understand the travel fee is due at booking I understand lab tests are billed separately to my insurance