Labs Direct Order Form Full Name *
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If a critical or life-threatening value should arise, a physician will be notified. Please provide the following:
Physician’s Name *
Clinic/Location *
Health Panel
*Female Health Panel - Includes CBC, CMP, Lipid Panel, TSH, Free T4 - $125
General Health Panel - Includes CBC, CMP, TSH - $75
*Lipid Panel - Cholesterol, HDL Cholesterol, Triglycerides - Included in Female and Male Panels - $25
*Male Health Panel - Includes CBC, CMP, Lipid Panel, TSH, FT4, PSA - $150
Thyroid Panel - Includes TSH, Free T4 - Included in Female and Male Health Panels - $50
Individual Tests
Complete Blood Cell Count (CBC) - included in Female Panel, General Panel, and Male Panel - $25
Comprehensive Metabolic Panel (CMP) - included in Female, General, and Male Panels - $25
Thyroid Stimulating Hormone (TSH) - included in Female, General, Male, and Thyroid Panel - $25
Prostate Specific Antigen (PSA) - included in Male Health Panel -$25
Hemoglobin A1c - $15
Vitamin D Level - $45
*Requires 8-10 hours of fasting
Select Test Month * January February March April May June July August September October November December
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