Toxicology Appointment Request

Toxicology Appointment Request

Thank you for choosing Clinical Labs of Hawaii.

Make sure you have all required documentation (e.g. requisition, referral/authorization, billing directives form, etc).

Provide the requested information below to proceed.

Do not send the Donor to our facility without a confirmed appointment from Clinical Labs of Hawaii and a photo ID.

DER/AUTHORIZED USER INFORMATION

Client Number

Bill To

Company Name

First Name

Last Name

Phone Number

Email

Confirm Email

Preferred Contact

Email: Phone:

DONOR INFORMATION

First Name

Last Name

Reason for Testing

Mode of Test

Service Requested

Please provide additional information that will help us process your request in the Comments.

Comments

Need Help?

Please contact a Toxicology Client Representative for assistance.