Patient Results Access Request Form

Patient Results Access Request Form

Complete the form below to sign up for access to our Patient Portal / Online Results.
Name *

First Name Last Name
E-mail *

Confirmation Email myname@example.com
Phone Number: *

Area Code Phone Number
Address: *

Street Address

Street Address Line 2

City State

Zip Code
Birth Date: *

Month Day Year
Birth Date:

Month Day Year
Terms of Service
Please read the linked TERMS OF SERVICE for accessing your results via the patient portal and check below if you accept the Terms of Service.
*

I have read, understood, and accepted the TERMS OF SERVICE.
HIPAA Notice for Privacy Practices
Please read our linked HIPAA NOTICE FOR PRIVACY PRACTICES in order to understand how your information is used and shared, and check below if you accept the HIPAA Notice for Privacy Practices.
*

I have read, understood, and accepted the HIPAA NOTICE FOR PRIVACY PRACTICES.
Privacy Policy
Please read our linked PRIVACY POLICY in order to understand how your information is used and shared, and check below if you accept the Privacy Policy.
*

I have read, understood, and accepted the PRIVACY POLICY.
Once you submit your request, we will contact you with further instruction on how to access your results.

Thank you!
Should be Empty:

Terms of Service