Request Test Results

Request Test Results

Want to check on a lab test and/or X-Ray results? You're in the right spot!

Our office will respond by phone. All your test results are private. Results will never be posted or stored on the Internet.

All information submitted on this form is confidential and The Adler Center will not sell or otherwise provide it to any third party.

*Fields in red or with asterisks are required.


Person Completing this Form if Other Than Patient:
Name:		Relationship:

Patient Information:
*Last name:		*First name:

*Date of birth: mm dd yyyy

*Preferred phone:		Alternate phone:
	Example: 555-555-5555

*May we leave a message if we are unable to reach you? Yes No

Email:

*My Provider:

My Location:

Please check all tests for which you would like results:

Blood Test
Pregnancy Test
Urine Culture
Pap Smear
Biopsy Report
Urine Culture
PSA (Male)
CT or MRI
	Name and location of facility:
Ultrasound or Mammogram
	Name and location of facility:
Other
	Name of test:
	Name and location of facility:

If you'd like a copy of this request, please print this page now.

Woodbridge
703-680-5327

Stafford
540-659-0928

Our image was sculpted by:
imagesculptor.com