Healthcare Provider Information Request

Please complete the form below to ensure timely delivery of your reports and communications regarding results. You may use this form to also update your existing information.

The details you provide will also be used to maintain our client records.

Your prompt response is appreciated and will help prevent any delays in processing and delivering your results.

* Indicates required

Purpose of Healthcare Provider Information Update *

Previous address * (where you are moving from)

Title *

Other Title:

Primary Specialty *

Secondary Specialty

OHIP/MSP Billing Number *

Healthcare Provider First Name *

Healthcare Provider Last Name *

Clinic / Hospital Name *

Current Clinic/Practice/Hospital Address * (used for report delivery)

City *

Postal Code *

Province *

Office Phone *

Office Fax *

Home phone, Cell phone, Pager, Other * (Must provide at least one for critical results notification)

Name of authorized person submitting this form *

I agree to receive critical results at the number above outside of regular office hours. *

I confirm that the information contained in this form is complete and accurate. *

Yes, I would like to receive updates on new tests, clinical practice guidelines, and diagnostic advancements. I understand that I can withdraw my consent at any time.

Reporting preferences *

Email *

Questions and Comments

Comments

Information collected on this form will be collected, used and/or disclosed in accordance with applicable privacy legislation for the purpose of client file management including report deliver and results communication. Questions about this collection may be directed to LifeLabs’ Privacy Office by calling 1-844-783-6677 or emailing privacy@lifelabs.com.