• (02) 8426-9745
    +63 9176203465 / +63 9212846893
  • contactus@premierelabincph.com

HOME SERVICE

To Proceed to your appointment for HOME SERVICE please fill-up the following:

Available Schedule
(Wednesday or Saturday):

First Name:

Middle Name:

Last Name:

Complete Address:

Birthdate:

Gender:

Civil Status:

Height:

Weight:

Phone No. / Landline:

Senior ID / PWD No.:

Date Issued:

Referring MD:

Hospital:

Request Procedures
(You may Viber/Messenger a picture of Doctors Request):

Result Ship Via
(Email, Viber, Deliver thru LBC):

If Vaccinated:

Vaccine Name:

Dose:

Date of Last Dose:

With Health Card:

Type of Health Card:

Account No. / Card No.

Company

Type of ID / Valid ID No.:

Name of Principal Holder:

Date of Birth: