Fountain Life Phlebotomy Request Form

Complete the form below, and we will contact you with your draw appointment.

Please note: First draw date request should be at least 14 days from the date of this request.

Fountain Life Requester
Location*
Requester Name*
First Last
Requester Email*
Fountain Life Member
Membership Type*
Member Name*
First Last
Member Phone*
Member Email*
Phlebotomy Request*
- Draw Site
- Mobile Draw (home/office) Patient phone number required
- Not Required
Draw Area Zip Code (required)
ZIP / Postal Code
Address for Draw (required)*
Street Address City State ZIP Code
Upload Order Requisition (required if shipping kit)
Accepted file types: pdf, Max. file size: 50 MB.
Ship Kit to
- Patient address
- Same as mobile draw address above
All kit orders placed after 1:45pm EST will ship next business day.
Kits can not be shipped to a PO Box
Patient Address for Kit Shipment (required)
Street Address Address Line 2 City State ZIP Code
Phelobotomy Appointment Date Request
Please allow 14 days for first requested date.
Do you want Boston Heart to Schedule the Draw?
- Yes
- No, send me local draw solutions. I will schedule the draw.
First Date/Time Request*
MM slash DD slash YYYY
Time*

: Hours

Minutes

AM/PM
Second Date/Time Request*
MM slash DD slash YYYY
Time*

: Hours

Minutes

AM/PM
Third Date/Time Request*
MM slash DD slash YYYY
Time*

: Hours

Minutes

AM/PM
Notes:

Fountain Life Direct Line: 508-739-8550

Phone: 877.425.1602
Email: billing@bostonheartdx.com

Boston Heart Diagnostics
200 Crossing Boulevard
Framingham, MA 01702