Fillable Warrenville, IL 60555 (630) 256-8308 4355 Weaver Parkway,

Fill Online, Printable, Fillable, Blank Warrenville, IL 60555 (630) 256-8308 4355 Weaver Parkway, Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Warrenville, IL 60555 (630) 256-8308 4355 Weaver Parkway,

On average this form takes 38 minutes to complete

The Warrenville, IL 60555 (630) 256-8308 4355 Weaver Parkway, form is 3 pages long and contains:

  • 2 signatures
  • 199 check-boxes
  • 50 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
411 E. Business Center Dr. Suite 107, Mount Prospect, IL. 60056
T: (847) 222-9546 | F: (847) 222-9547 | support@DHALab.com
SUBMIT ORDERS BY FAX: (847) 222-9547 or EMAIL: support@DHALab.com

   
 (KP, Cu, Zn, Histamine) Urine & Blood $152.00 $260.00
 (KP, Cu, Zn, Histamine, Ceruloplasmin) Urine & Blood $172.00 $308.00
(KP, Cu, Zn, Histamine, Ceruloplasmin, Vit D, TSH, CMP) Urine & Blood $192.00 $412.00
(KP, Cu, Zn, Histamine, Ceruloplasmin, Vit D, TSH, CMP, Homocysteine) Urine & Blood $212.00 $460.00
   
 Serum $25.00 $66.00
 Serum $25.00 $49.00
 Whole Blood $25.00 $68.00
 [706994] Plasma $25.00 $70.00
   
 Urine N/A $94.00
TSH [004259] Serum $25.00 $50.00
[081950] Serum $25.00 $35.00
 Plasma $25.00 $49.00

   
 Plasma Doctor’s Data $216.00
 Urine Great Plains $233.00
 Hair Doctor’s Data $104.00

Serum / DBS
Great Plains $264.00
TEST SELECTION
connued on page 2
Pages Aached: 1 2 3 (Please circle # of pages with the order)


4355 Weaver Parkway, Suite 110
Warrenville, IL 60555
(630) 256-8308


NAME PREFERRED CONTACT

CREDIT CARD NUMBER EXP. DATE CCV CARDHOLDER NAME (Please print) SIGNATURE
Personal check, cashiers check, or money order enclosed (Make checks payable to DHA Laboratory)

NAME OF POLICY HOLDER PATIENT RELATION TO POLICY HOLDER
Self Spouse Child Other:
INSURANCE COMPANY P.O. BOX TO SUBMIT MEDICAL CLAIMS LISTED ON BACK OF CARD (Only include if provided on card)
INSURANCE ID # GROUP # (Only include if provided on card) ADDITIONAL INFORMATION LISTED ABOUT PLAN

 DATE

PATIENT NAME (Last, First)
RESPONSIBLE PARTY (Required for persons under 18)
GENDER
Male Female
BIRTH DATE (MM/DD/YYYY)
ADDRESS CITY, STATE, ZIP
PRIMARY PHONE NUMBER SECONDARY PHONE NUMBER
EMAIL
TOTAL:


NOTES:
click to sign
signature
click to edit
click to sign
signature
click to edit
TEST SELECTION - connued
PATIENT NAME (Last, First):
Pages Aached: 1 2 3 (Please circle # of pages with the order)
connued on page 3
STANDARD CLINICAL CHEMISTRY TEST MENU
   
 (CMP 14, CBC, Lipid Panel, LDH, GGT, Iron & TIBC, Uric Acid, Phosphorous) Blood $30.00 $60.00
 (TSH, Free T3, Free T4, Total T4) Blood $50.00 $102.00
(TSH, Free T3, Free T4, Total T4, Reverse T3, Total T3, T3 Uptake, Thyroglobulin Ab, TPO Ab) Blood $80.00 $198.00
(CRP hs, Homocysteine, Insulin, Hemoglobin A1c, Fibrinogen) Blood $83.00 $134.00
(Hemoglobin A1c, Uric Acid, Phosphorus, Magnesium Serum, LDH, GGT, Iron & TIBC, Ferrin,
CRP hs, Homocysteine, Thyroid Prole II, Free T3, Reverse T3, Free T4, TPO Ab, Thyroglobulin Ab, Vitamin D 25-Hydroxy,
Fibrinogen Acvity, CMP (14), Lipid Panel W/ Total Cholesterol, HNK1 (CD57), CBC, Urinalysis Complete)
Blood & Urine N/A $280.00






Cost
 [006049] Blood $17.00 $46.00
ACTH [004440] Plasma $49.00 $91.00
ADH [010447] Plasma $39.00 $76.00
 [002253] Serum $38.00 $78.00
 [001081] Serum $22.00 $62.00
 [004374] Serum $75.00 $111.00
 [071548] Blood $63.00 $100.00
 [007054] Plasma $51.00 $93.00
 [001396] Serum $18.00 $48.00
ANA [164947] Serum $15.00 $38.00
 [790348] Urine $121.00 $165.00
 [004705] Serum $38.00 $81.00
 [096289] Serum $143.00 $187.00
 [006031] Serum $28.00 $84.00
[140889] Plasma $57.00 $96.00
 [001214] Serum $16.00 $53.00
 [010108] Serum $25.00 $66.00
 [120766] Serum $26.00 $67.00
 [006627] Serum $20.00 $51.00
 [081091] Serum $75.00 $112.00
 [001016] Serum $12.00 $42.00
[163005] Serum $42.00 $79.00
 [706500] Serum $69.00 $100.00
 [001529] Blood $48.00 $90.00
 [005009] Blood $14.00 $40.00
 [505271] Blood $37.00 $75.00
 [001065] Serum $12.00 $46.00
 [071522] Plasma $62.00 $91.00
 [002154] Serum $23.00 $64.00
 [322000] Serum $14.00 $35.00
 [120251] Serum $55.00 $96.00
 [006452] Serum $38.00 $80.00
 [004220] Plasma $131.00 $170.00
 [001834] Serum $38.00 $81.00
 [004330] Plasma $131.00 $171.00
 [104018] Blood $22.00 $63.00
 [002402] Serum $58.00 $101.00
 [001362] Serum $22.00 $63.00
 [121251] Serum $57.00 $96.00
 [006494] Serum $32.00 $68.00
 [096727] Serum $32.00 $68.00
 [115188] Plasma $41.00 $82.00
DHEA [004100] Serum $32.00 $72.00
 [004020] Serum $25.00 $66.00
 [500142] Serum $115.00 $151.00
 [096248] Serum $29.00 $66.00
 [096230] Serum $29.00 $66.00
 [096735] Serum $29.00 $66.00
 [096255] Serum $42.00 $79.00
 [010272] Serum $23.00 $58.00
 [303754] Serum $13.00 $41.00
 [004515] Serum $19.00 $61.00






Cost
 [500649] Serum $59.00 $100.00
 [004564] Serum $37.00 $80.00
 [004598] Serum $16.00 $56.00
 [001610] Blood $25.00 $66.00
 [002014] Serum $17.00 $58.00
 [266015] Red Blood Cell $36.00 $76.00
 [028480] Serum $19.00 $69.00
 [001958] Serum $12.00 $40.00
 [001032] Serum $12.00 $40.00
 [007700] Blood $68.00 $123.00
 [004275] Serum $46.00 $101.00
 [162289] Serum $30.00 $72.00
 [140659] Serum $21.00 $61.00
 [001453] Blood $17.00 $60.00
 [161075] Serum $32.00 $68.00
 [138529] Serum $102.00 $145.00
 [167120] Blood $126.00 $167.00
 [505026] Blood $40.00 $78.00
 [010540] Serum $21.00 $61.00
 [002295] Serum $47.00 $90.00
 [004333] Serum $21.00 $76.00
 [070034] Serum $82.00 $121.00
 [001321] Serum $15.00 $56.00
 [001842] Serum $45.00 $84.00
LDH [001115] Serum $12.00 $41.00
 [007625] Blood $17.00 $45.00
 [717009] Blood $17.00 $45.00
 [146712] Serum $46.00 $102.00
 [001404] Serum $19.00 $60.00

 [221010]
Serum $14.00 $55.00
 [120188] Serum $46.00 $84.00
[163600] Serum $57.00 $96.00
 [160325] Serum N/A $90.00
[001537] Serum $22.00 $63.00
[080283] Red Blood Cell $26.00 $66.00
[085324] Blood $52.00 $91.00
[706961] Serum $63.00 $100.00
[500124] Serum $80.00 $120.00
MMR [058495] Serum $48.00 $89.00
MSH [010421] Plasma $98.00 $151.00
MTHFR [511238] Blood $106.00 $149.00
[163741] Serum $34.00 $74.00
[884247] Blood $63.00 $119.00
[823430] Whole Blood $50.00 $88.00
[002071] Serum $14.00 $48.00
[008623] Stool $30.00 $71.00
[001024] Serum $12.00 $41.00
[001180] Serum $14.00 $55.00
[140707] Serum $47.00 $85.00
[004317] Serum $20.00 $62.00
[010322] Serum $18.00 $61.00
TEST SELECTION - connued
#1005 rev081921
PATIENT NAME (Last, First):
Pages Aached: 1 2 3 (Please circle # of pages with the order)

   
 Saliva DiagnosTechs $210.00

Urine / Plasma
Great Plains $329.00
 DBS Doctor’s Data $132.00
 Whole Blood Cell Science Systems (ALCAT) $219.00
 Stool Doctor’s Data $301.00
 Stool Doctor’s Data $388.00
 Urine Precision Analycal $210.00
 Urine Precision Analycal $330.00
 Urine Precision Analycal $210.00
 DBS Genova $180.00
 Plasma Genova $264.00
 Stool Doctor’s Data $447.00
 Stool Diagnosc Soluons $343.00
 Stool Diagnosc Soluons $398.00
 Urine Great Plains $144.00
 Saliva Great Plains $282.00
 Urine Great Plains $329.00
 Urine Great Plains $264.00
 Urine Doctor’s Data $170.00
 Hair ARL $123.00
 Blood Genova $220.00
 Urine Genova $153.00
 Blood Genova $264.00
 Whole Blood SpectraCell $402.00
 Blood & Urine Genova $468.00
 Urine Great Plains $329.00
 Urine Genova $330.00

2 hr. Breath / 3 hr. Breath
Genova $221.00
 Urine Doctor’s Data $162.00
STANDARD CLINICAL CHEMISTRY TEST MENU (connued)







Cost
[015610] Plasma $29.00 $72.00
[322777] Serum $14.00 $54.00
[005280] Whole Blood $22.00 $57.00
[006064] Blood $14.00 $54.00
[006502] Serum $17.00 $56.00
[005215] Blood $14.00 $54.00
[716910] Serum $46.00 $90.00
[082016] Serum $34.00 $90.00
[001198] Serum $22.00 $62.00
[010389] Serum $27.00 $68.00
[070104] Serum $32.00 $73.00
[002188] Serum $15.00 $56.00
[001156] Serum $16.00 $46.00
[001974] Serum $17.00 $46.00
[001149] Serum $16.00 $46.00
[140103] Serum $39.00 $81.00
[821342] Blood $45.00 $84.00
[006685] Serum $20.00 $61.00
[006684] Serum $28.00 $70.00
[000620] Serum $23.00 $59.00







Cost
[027011] Serum $23.00 $45.00
[140749] Serum $78.00 $119.00
[006676] Serum $19.00 $59.00
[004937] Serum $39.00 $80.00
[004280] Serum $79.00 $118.00
[001057] Serum $12.00 $53.00
[003772] Urine $17.00 $56.00
[117021] Serum $55.00 $93.00
[004861] Serum $34.00 $66.00
[017509] Serum $23.00 $63.00
[001503] Serum $16.00 $56.00
[004655] Plasma $26.00 $68.00
[001805] Plasma $40.00 $82.00
[081950] Blood $26.00 $37.00
[081091] Blood $75.00 $112.00
[070140] Serum $28.00 $68.00
[121200] Serum $83.00 $116.00
[451382] Blood $299.00 $355.00
[070029] Red Blood Cell $62.00 $101.00
 Pay this amount when billing insurance. No addional charges will be administered to the paent in the event tests are not paid for by insurance.
 Place an order for one of DHA’s panels and add the addional tests on for a greatly reduced price.


Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Warrenville, IL 60555 (630) 256-8308 4355 Weaver Parkway,

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 10 June 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document