Clinical Practicum Registration Form | EMS Proficient Mobile Phlebotomy LLC

Clinical Practicum, Lab Access & Board Prep Intake Form

EMS Proficient Mobile Phlebotomy Service LLC

Office Line;(813) 733-7126| Email: skills@emsphlebotomy.org

Section 1. Application Information

First name

Last name

Phone

Date

Date of Birth

Month

Day

Year

Address

Employer/Sponsoring Agent

Section 2. Service Selection

Service Selection

Section 3. Background Verification & Upload

Upload Required Documents: (Please upload your unofficial online school transcript, screenshot of your student course dashboard, copy of an active Florida medical license, or lapsed phlebotomy certification).

Please upload a copy of the front of your Florida Drivers License or Identification card

Please upload a copy of the back of our Florida Drivers License or Identification card.

Section 4. Legal Disclosures

I understand that EMS Proficient Mobile Phlebotomy Service LLC is a commercial mobile specimen collection company and clinical, laboratory facility, not a postsecondary vocational school or academy.

Iverify that all fees paid under this agreement are strictly allocated towards professional board examination preparation materials, classroom workspace rental, and laboratory consumable supplies.

I acknowledge that completion of this prep workshop or clinical check-off session does not automatically grant a phlebotomy credential.

I agree to follow all OSHA, CLIA, and facility safety protocols directed by the on-site instructor.

EMS Pro Mobile Phleb Service LLC is a commercial mobile specimen collection company and a CLIA-waived clinical service provider. We are not a postsecondary educational institution licensed by the Florida Department of Education Commission for

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Signature Date

(813) 733-7126 By contacting us via SMS with your mobile number, you consent to receive Customer Care text messages from EMS Proficient Mobile Phlebotomy Service. Msg & Data rates may apply. Reply "STOP" at any time to opt out.'

Address: 1808 James L. Redman Pkwy, Ste 115 Plant City, FL 33563 Phone Number: (813) 733-7126 Email: info@emsphlebotomy.org

Address: 1808 James L. Redman Pkwy, Ste 115
Plant City, FL 33563

Phone Number: (813) 733-7126

Email: info@emsphlebotomy.org