Refer | LaboratoryAssist

ReferAli2026-10-06T15:18:31-06:00

Contact us: 888-531-2030

Refer a patient

For providers only.
Please use this form to submit an referral for lab tests. LaboratoryAssist will reach out to the patient for scheduling.
Lab Tests
Lab Tests
Test Code (Optional) Test Name

Please list lab tests. Include test numbers if known
Test codes type?*
Diagnosis
Diagnosis
Hidden
Diagnosis Codes Selected
Additional Instructions
Additional instructions for our schedulers
Provider Name*
Data presented from NPI database. You can update the address on the next page.
Please verify that provider data is accurate
Ordering Provider
Hidden
NPI
Provider Name
First Last
Provider Address
Street Address Address Line 2 City State ZIP Code
Provider Phone
Provider Fax
If no fax number is provided, provider will need to obtain reports from the patient.

Patient Information
Patient Name*
First Last
Date of birth*
MM slash DD slash YYYY
Gender
- Male
- Female
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Please ensure it is accurate and patient is reachable at this number.
Email*
Note to providers
Patients must be informed to call LaboratoryAssist at 888-531-2030 to schedule their appointment
Sign Order
Please certify*
- I am electronically signing this order for lab tests. I acknowledge and agree that submission creates an electronic signature that has the same legal effect and validity as my written signature.
Please confirm*
- Patient is aware about this referral and has been informed to call LaboratoryAssist at 888-531-2030
Phone
This field is for validation purposes and should be left unchanged.

Already have an order?

Fax Referral

Fax a completed referral to
972-445-9960

Download Order Form

Upload Referral

Submit a referral using the secure upload form.

Upload Referrals

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