Services to be Rendered (please check all that apply)
INTAKE FORM FOR OUTSIDE CLINIC SERVICES
Services provided in house:
Labs sent to LabCorp for processing: (may require additional venipuncture fee)
A price sheet is available upon request. Please email request for pricing to AMarvel@henryfertility.com.
*Please provide LabCorp account for billing if applicable. If not applicable, fees per draw are due on the day of service.
**If insurance is to be utilized for services rendered, there is a $50.00 monitoring program fee per service, per day, due on the day services are rendered. For the labs to be sent to Lab Corp for processing in the case of insurance coverage, Lab Corp will bill patient or agency directly after sending their claims to insurance.