Medical Results Request Page

Medical Results Request Form

Instructions:
Enter the following:

1. Your email address in the "From:" field (i.e. me@yourisp.com).

2. Your First and Last name in the "Patient Name:" field (i.e. John Jones).

3. A telephone number where you can be reached during the day in the "Telephone Number:" field (i.e. 714-555-1212).

4. The date of the medical test for which you are requesting results in the "Date of Test:" field (i.e. mm/dd/yyyy).

5. Click on the "Type of Test:" field to select the type of test that was performed (i.e. Biopsy).

6. The location where the test was performed in the "Place of Service:" field (i.e. St. Josephs).

7. Click on the "Send" Button.

From:
Message:	Please provide medical results to me either by email or by telephone using the patient information below:
Patient Name:
Telephone Number:
Date of Test:
Type of Test:
Place of Service: