Telehealth Appointment Request Form

If you would like to schedule a telehealth appointment with a Healthcare Professional please fill out and submit the information below. You will be called to schedule a virtual appointment. We look forward to serving you!

First Name *

Last Name *

Date of Birth *

Order/Accession Number (if available)

Primary Phone *

Email *

Lab Name *

For your convenience, we have a HIPAA-compliant file upload utility that’s faster and more reliable than fax.
Please upload any lab reports here:

To select multiple files, hold down the CTRL or SHIFT key while selecting.

Please enter any questions you would like to have answered during the consult

Consent Statement
I have read the Consent Statement and give my consent to proceed with accessing my lab information