Portal Access Form

17774 Preston Road, Dallas, TX 75252

Please send patient's demographics and copy of insurance card with requistion

Patient Information

Names:

Address:

Phone Number:

Email:

Fax:

PROVIDER NAME

NPI

Do you have more than one location? If so, please provide the location details.

How do you want to get your reports? - (Select the option )

Email Fax

The benefit of the portal access, you have access to your reports should the fax or email option fails. Would you like portal access? (Circle Yes or No)

Yes No

Please complete all form fields, incomplete requisition form will delay results

Reliance MedLabs LLC was established to meet the growing needs of our community by providing you with the comfort and convenience of lab services by bringing the lab to you.

Reliance MedLabs and our sister company MedLife Diagnostics have been in the healthcare industry for several years extending innovative patient care through convenient mobile lab diagnostic services and patient testing.

Portal Access Form

Please send patient's demographics and copy of insurance card with requistion

Patient Information

PROVIDER NAME

NPI

Do you have more than one location? If so, please provide the location details.

How do you want to get your reports? - (Select the option )

The benefit of the portal access, you have access to your reports should the fax or email option fails. Would you like portal access? (Circle Yes or No)

Please complete all form fields, incomplete requisition form will delay results

Quick Links

Diagnostic Solutions

Contact Info

Reliance Med Labs - Dallas Office

Reliance Med Labs - Houston Office

MedLife Diagnostic Services