CMBA Registration Form

Please fill out the following form:

Name:		Date of Birth:	Location:
Address:		Physician:	Time:
City:		State:	Zip Code:
Phone:		Email:

	Please select the type of test you would like to have performed from the list below:
	CMBA - $49.00 - CMBA
	CMBA w/PSA - $66.00 - CMBA w/PSA
	CMBA w/PSA/COLO - $72.00 - CMBA w/PSA/COLO
	CMBA/Colo - $55.00 - CMBA/Colo

No eating or drinking anything 12-14 hours prior to test except water. You may take your regular medications - unless other wise advised by your physician. If you do not receive confirmation of your appointment within five days please call 800-808-5287 or 570-723-8436.

Laurel Health System • 22 Walnut Street • Wellsboro, PA 16901 • (570) 723-0500 • 800-808-LAUREL (5287)
©2002 Laurel Health System • Site Designed & Maintained by JPL Productions

Every effort has been made by the authors of this Web site to provide accurate, up-to-date information. However, the medical knowledge base is dynamic and errors can occur. By using the information contained herein, the viewer willingly assumes all risks in connection with such use. Laurel Health System shall not be held responsible for errors or omissions in information herein or liable for any special, consequential, or exemplary damages resulting, in whole or in part, from any viewer's use of or reliance upon this material.