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.

1. Medical Doctor Consult
For evaluation and treatment of a specific medical concern or ongoing condition. You’ll meet with a licensed physician who can provide clinical guidance.
2. Functional Medicine Consult
For a more holistic, root-cause approach to your health. These visits focus on lifestyle, nutrition, lab interpretation, and long-term wellness planning rather than short-term symptom relief.
3. I’ve recently taken a test and seek treatment/prescription options
I’ve recently taken a test and seek treatment/prescription options. For patients who have already completed labs, at-home tests, or other assessments and would like to review results and discuss potential prescriptions or next steps in treatment.

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