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Most patients do not have a copy of their laboratory or pathology report. The procedure to obtain it is very simple. Simply ask the physician who performed the biopsy or surgical procedure for a copy of your report.

Please print this form and attach a copy of the laboratory report.

Please mail it to:

The Doctor's Doctor
3870 Del Amo Blvd. Unit 507
Torrance, CA 90503-7701

You may also fax this printed form and laboratory report to us at 310-347-4381. If you have any questions, please contact us by phone at 310-561-8503 and ask for The Doctor's Doctor.

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PART 1: Patient Data

Last Name: First Name:

Birth Date: Male Female

Address

Home Telephone #: Work Telephone #:

E-Mail Address: Fax #:

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PART 2: Submission of Reports

How are you submitting your original pathology report(s) to The Doctor's Doctor?

Fax Mail

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Part 3: Mailing Addresses

Send my translated report to me at:

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PART 4: Payment

Personal Checks may be written to: Dermatopathology Institute

NOTE: If you do not submit payment details via this form, we will contact you by telephone to verify your credit card information.

# of Reports Being Translated		x $200=$
Total Fee		$

Visa MasterCard

Card # Expires

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PART 5: Consent

By signing here on a hard copy of this form, I give my permission for The Doctor's Doctor to prepare a translated report for me. I have read and agree to the disclaimer below (name of client or legal guardian):

 

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Disclaimer:

The information and advice contained in or made available through this website is for educational purposes only and is not intended to replace the services of a health professional or to be a substitute for medical advice of physicians.   The user should regularly consult a physician in all matters relating to his or her health, particularly in respect to any symptoms that may require diagnosis or medical attention.  The Doctor's Doctor makes no representations or warranties with respect to any treatment, action, or application of medication or preparation by any person following the information offered or provided within or through this website.   Neither The Doctor's Doctor nor any of its affiliates will be liable for any direct, indirect, consequential, special, exemplary, or other damages arising therefrom. The Doctor's Doctor has not reviewed any of the original diagnostic material and the original diagnostic pathology report was performed at a facility not associated with The Doctor's Doctor

 

Last Updated July 16, 2008

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Read the Medical Disclaimer.

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