Request For Test Results

Want to check on a lab test and/or ultrasound results? You’re in the right spot!

Our office will respond by phone - and your test results are private. Results will never be posted or
stored on the internet

Obstetrics and Gynecology Associates of Hampton, or The Women's Bladder Center will not sell or otherwise provide your name, address or other information to any third parties.

* Fields in color or with asterisks are required.

*Last name:

*First name:

Person Completing this Form if OtherThan Patient:

Name:

Relationship:

*Home Phone:

Work phone:

Ext:

*Email:

*Date of birth:

yyyy

*My Provider:

Please check all tests for which you would like results:

Common Tests:

	Pap Smear

	Beta hCG

	Prenatal Labs

	GC/Chlamydia

	MSAFP Quad Screen

	Urine Culture

	Early Screen

	FSH

	Thyroid Levels

	Blood Test

Other

Name and Location of Facility:

Additional requests:

Mammogram

Name and Location of Facility:

Additional requests:

Bone Density Test

Name and Location of Facility:

Additional requests:

Ultrasound

Name and Location of Facility:

Additional requests:

Biopsy report

Name and Location of Facility:

Additional requests:

Surgical Pathology

Name and Location of Facility:

Additional requests:

Other

Name and Location of Facility:

Additional requests:

If you’d like a copy of this request, please print this page before clicking Submit

Click Submit when complete - the form will be e-mailed to us

Thank You!

Smithfield, Yorktown, James City County, Williamsburg, Newport News, York County, New Kent, Poquoson
Smithfield Gynecology, Yorktown Gynecology, James City County Gynecology, Williamsburg Gynecology, Newport News Gynecology, York County Gynecology, New Kent Gynecology, Poquoson Gynecology