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