CASH/DIRECT PAY – Lab Work Request

CASH / DIRECT PAY Lab Work Request

(This means paying direct via credit card)

Date

If you have an appointment already set in our office with Dr. Russell or another practitioner, please list the date (recommended 2 weeks from date of lab draw to assure it's received).

I am a...

Current Patient
New Patient

Full Name

Gender

Height

Weight

Phone Number

Date of Birth

Address

Street Address

Single Line Text

Street Address 2

City

State/Province

Zip Code

Briefly describe what you are being seen for, or your concerns:

COMPREHENSIVE WELLNESS PANEL - $312

Specimen Type: Blood. Description: The Comprehensive Wellness Panel provides an in-depth health screening.This package includes: HS-CRP, Lipid Panel, ApoB, Insulin, HbA1c, Homocysteine, Vitamin D, Folate, Vitamin B12, Omega Check, Ferritin, Iron & IBC, T4 Free, T4 Total, T3 Free, T3 Total, TSH, Thyroid Peroxidase AB, Thyroglobulin AB, Reverse T3, Comprehensive Metabolic Panel and CBC w/Differential - $312.00

FEMALE HORMONE PANEL - $259

Includes Estradiol, Estrone, Estriol, Progesterone, DHEA-S, Testosterone Total, Sex Hormone Binding Globulin, Luteinizing Hormone, FSH, Leptin - $259.00

MALE HORMONE PANEL - $120

Includes, Testosterone Total, Sex Hormone Binding Globulin, Estradiol, DHEAS, - $120.00

LEPTIN HORMONE (*If Weight is a Problem) - $45

Leptin protein, hormone acting mainly in the regulation of appetite and fat storage. - $45.00

Total

$0.00

Stripe Credit Card

Please list any additional tests outside of a Comprehensive Wellness, Female or Male Hormone Panel that you would like run (ie: leptin, EBV, etc.) These will incur an additional fee to be run on your card. The doctor may request additional labs after your evaluation.

Please allow 24-48 business hours to receive your lab orders via e-mail. Print them off to take to the lab with you.

You will be going to a QUEST for your blood draw. You can do an Internet search for the lab closest to you. You may or may not need to call ahead to book a morning appointment. We suggest you go first thing in the morning. (We know you can show up and get in pretty quickly as we have heard from many patients.)

You will fast and consume ONLY WATER from 9pm the night before your lab draw.

We will send your results to you when they are received. IF YOU ARE A CURRENT PATIENT, PLEASE GO AHEAD AND GET YOUR FOLLOW-UP APPOINTMENT BOOKED NOW – 2 weeks out from day of lab draw. (This is recommended as we have been very busy.) You may choose an in-house visit or video conference.

Thank you!

CASH/DIRECT PAY – Lab Work Request

CASH / DIRECT PAY Lab Work Request

TEXAS FUNCTIONAL / HOLISTIC MEDICINE

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