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Lab Request Form

This laboratory request questionnaire allows your provider to gather important information regarding your current symptoms, medical history, and treatment goals. The information provided will be used to determine the most appropriate laboratory evaluation prior to your visit.

Let's start with your personal details

Driver's License

Please upload a clear copy of your valid government-issued photo ID (driver's license, state-issued ID, passport, or military ID). We use this information to verify your identity and confirm that you are eligible to receive telehealth services. At this time, Elite Health & Hormone is only able to provide care to patients physically located in Utah or Colorado at the time of their appointment.

Have you had any labs completed in the last 30-60 days?

A
B

Are you currently taking any prescription medications, over-the-counter medications, vitamins, supplements, or hormone therapies? If so, please list all current medications below.

Please select all services you are interested in. Your responses will help us determine which laboratory tests may be appropriate prior to your provider appointment, allowing your provider to review your results and develop a personalized treatment plan based on your individual health needs and goals.

A
B
C
D
E
F

Is there any additional information you would like your provider to know before your laboratory request is submitted? Please include any symptoms, concerns, or relevant medical information that may help guide your laboratory evaluation.

By signing below

By signing below, I certify that the information provided on this form is true and accurate to the best of my knowledge. I understand that this questionnaire is used to assist my provider in determining the most appropriate laboratory testing prior to my appointment. I acknowledge that completion of this form does not guarantee that specific laboratory tests or treatments will be ordered, and that all laboratory requests are subject to the provider's clinical judgment.
Signature