Select Inquiry Type * (if your test is not listed, please specify name of test in the message box below)

First Name (As it appears on Health Card)*

Last Name (As it appears on Health Card)*

(Please provide a secure email which only you have access to.
You will receive result status to this email)

Health Card Number & Version Code (last two letters) *
(must be provided 01234567890-AA)
(For Out of Country/Cash visits enter 01234567890-AA)

Phone Number (Home or Cell xxx-xxx-xxxx)*

Date of Birth (YYYY-MM-DD)*

Please specify specific test(s) if not listed above

When was the test done*

Day(s) Week(s) Month(s)

I have read, understood and agree to the Terms of Service. I understand that if this is a medical emergency, I will call 911 or go to nearest emergency department for immediate care.*