Home Blood Sampling Appointment

Home blood sampling is available by appointment only, Monday to Friday (07:30–08:30), excluding public holidays. Availability is subject to the patient’s location and operational feasibility.

Please complete all required fields and upload a valid medical prescription.
Incomplete requests will not be processed.

SECTION 1 — Patient Information

Name

First

Last

Gender

Male

Female

Other

Date of birth

Phone number

Email address

Email address confirmation

SECTION 2 — Address Information

District (Khan)

Commune (Sangkat)

Full address

Google map location

SECTION 3 — Medical Request

Upload Medical Prescription (File upload)

Maximum file size: 5MB

SECTION 4 — Appointment Request

Date of appointment

Time

SECTION 5 — Payment Method

Preferred Payment Method (Multiple choice — Required)

Cash

Bank transfer (QR code)

SECTION 6 — Consent (Checkbox — Required)

I agree to be contacted by the laboratory for confirmation or clarification

Yes

If you are human, leave this field blank.