Portal Access Form

17774 Preston Road, Dallas, TX 75252

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

Patient Information

Provider Name
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