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Available Forms

Alignment Care Center Appointment Request Alignment Referral Form Back Pain E-Visit Blood Pressure Log Blood Sugar Readings Cold/Sinus/Cough/Throat/Respitory Infaction E-Visit Conjunctivitis/Pink Eye E-Visit Depression Screening (PHQ9) Health Care Question Lab Result Follow-up Question Living Will/Health Power of Attorney Medical History/Preventative Update Medicare Wellness Exam Prescription Refill Request Referral Question Specialist/Urgent Care or Hospital Visits Survey Triangle Medical Group Urinary Tract Infection E-Visit Yeast Infection E-Visit

Lab Result Follow-up Question

Please use this form to request a copy of your labs or to ask a question about upcoming or reported labs

Choose your Medical Practice *

Name *

Date of Birth *

Question or Request

Please tell us the nature of your request and if available include the date that your labs were drawn

Preferred Contact Method

Email

Home Phone

Cell Phone

Office Phone

List all that apply

Preferred Contact Number or Email

* Required field