Phlebotomist Request Form

If you are in need of a phlebotomist (sample taker) to perform a blood test in a location that suits you please provide us with the following information. We will assess this and provide an option within 3 working days.

Your First Name

Your Email Address

Your Last Name

Your Phone Number

Do you require a phlebotomist because you a medical practitioner or patient?

Medical Practitioner

Patient

Other

If you answered 'Other' tell us the reason for using this service here...

Will the patient have pre-supplied test kit?

Yes

Will the patient have an NHS Test Request Form?

Yes

No, Private Test Request Form

If 'No' please describe...

Is the patient 18 years of age or above?

Yes

Preferred Location for Appointment

Preferred Appointment Date

Patient Contact Number

I declare that the information I have provided is accurate & complete.

I understand that The Phlebotomy Centre cannot gaurantee all requests are fulfilled.

I understand that a fee will apply if a practitioner is placed succesfully. Fees will be discussed before the appointment is confirmed.

I have checked that the Preferred Appointment Date is at least 10 days away from today.

Thanks for submitting! We will be in touch soon.

The Phlebotomy Centre

Email:

Visit us: Ground Floor, Vantage House, Crown Street, Bolton, Bl1 2RU

Call us: 03333580381