Your Name (required)

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Date of Your Doctor Visit

Where Did You Go?
doctor visitemergency room visitinpatient hospital visitspecial testingOther

Full Name of Doctor

Full Name of Practice, Clinic or Hospital Where Test was Performed

Full Address of Practice, Clinic or Hospital

Was Special Testing Performed?
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Which Doctor Ordered the Test?

Date Test Was Ordered

Name of Special Testing Clinic
BIOTAP Medical

Address of Special Testing Clinic
716 W Main St Suite 100A, Louisville, KY 40202

What Special Test Was Performed?
xrayMRICTbloodworkcolonoscopyendoscopyEKGechocardiogramdopplerbone density studyother

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