ULC - Book Appointment Form

Book an Appointment

Page 1
Full Name:*

First NameLast Name
Email:*
Phone Number:*
Gender:*

MaleFemale
Date of Birth:*

MonthDayYear
Appointment (246 E Janata Blvd, Suite 115, Lombard, IL 60148)*
*After clicking next you will be redirected to remaining form fields where you can enter information required for Lab Testing.

Book an Appointment

Page 2
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Pregnancy Status:*

YesNoN/A
Race:*

Amer Ind/AlaskanWhiteBlack/Afr AmerAsianNative Hawaiian/Pacific IslanderOther
Ethnicity:*

Hispanic/LatinoNon-Hispanic/Non-LatinoOther
Billing information:*

Self-PayCommercial InsuranceMedicare
RESPIRATORY PANEL and/or SARS-COVID-19 (check all that apply):*

AdenovirusCoronavirus 229ECoronavirus HKU1Coronavirus NL63Coronavirus OC43SARS-CoV-2Human MetapneumovirusHuman Rhinovirus/EnterovirusInfluenza A including subtypes. H1, H3 and H1-2009Influenza BParainfluenza Virus 1Parainfluenza Virus 2Parainfluenza Virus 3Parainfluenza Virus 4Respiratory Syncytial VirusBordetella parapertussisBordetella pertussisChlamydia pneumoniaeMycoplasma pneumoniaeAll Tests
Provider Information
Referring Physician:*
Physician Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Doctors Order:*

Cancelof
Facility/Group (optional)
NPI Provider Nr (optional)
Diagnostic Codes (optional)
(ICD-10 codes)
Clinical Information (optional)
(date of onset/exposure, travel, history, previous lab results)
Signature of Patient or Legal Guardian:

Clear
Should be Empty:

Book an Appointment