BioCentra Diagnostics, A state of art medical laboratory for all your needs

Location

First name*

Middle name

Last Name*

Email*

Gender*

Date of Birth*

Mobile Phone*

Address*

City*

State*

Zip*

Driver’s License/SSN/Passport Number*

Driver’s License/SSN/Passport*

*Upload image

Others

Appointment Date*

Available Times*

Patient Signature*

Date*

All the information submitted above is correct.
I agree not to claim reimbursement from any insurance company.

You must agree before submitting.

TBioScan™ TBI Advanced Test