Request for Test Results (NOT LAB RESULTS)

CLICK HERE if you meant to request lab results.

Patient Name *
Patient Name
Your Name
Your Name
Leave blank if you are the patient.
Enter the last 4 digits of the patient's Social Security Number
Patient's Date of Birth *
Patient's Date of Birth
Phone *
Phone
Enter the best phone number where you can be reached in case the doctor needs to contact you.
Alternate Phone
Alternate Phone
Enter an alternate phone number where you can be reached.
Examples: •chest x-ray of chest •x-ray of knee •ultrasound of abdomen •CT of head •MRI of neck… Try to be specific.
When did you get the test done? *
When did you get the test done?
If you can't remember the exact date, just enter your best guess.