Los Santos Emergency Services

Patient Info:

Full Name *
First and Last Name: "John Doe"

Date of Birth *

Phone Number *
Your Current Telephone Number

Place of Residence *
Street Number and Name, City/County, State OR N/A if None

Emergency Contact Info (Optional)

Full Name
First and Last Name: "John Doe"

Phone Number
Your Current Telephone Number

Place of Residence
Street Number and Name, City/County, State OR N/A if None

Lab Work Request:

Requested Test *
Select ONE

Eye Examination
Urinalysis
Blood Test
MRI Scan
X-Ray
Hearing Test
Dental Check Up

Reason for Testing *
Select ONE

Pre-Employment
Follow-Up
Post-Accident
Reasonable Suspicion
Other (explain below)

Additional Information *
Further information on the reason for testing

Signature:

Sign Here *
First and Last Name: "John Doe"

Date *

What does LSES stand for?:
This question is a means of preventing automated form submissions by spambots.