AVRT Consult Order Form

Let's begin your journey! Please complete the form below.

Your AVRT journey begins with a comprehensive health history questionnaire. A COC physician will review your health history and order laboratory tests as appropriate. You will receive an order for laboratory tests, which can be performed at Quest Diagnostics or another lab of your choice. Once the lab test results have been received, you will have a telehealth consultation with a COC physician who will review your information with you to develop a personalized plan to help you to optimize your health.

*Please note that the cost of your lab tests are separate from your consultation with the physician, and will be billed separately by the laboratory. Your out-of-pocket costs for lab tests will vary based on your insurance coverage co-pay and deductible, and network status.

Patient Name*
First Last
Patient Date of Birth*
MM slash DD slash YYYY
Biological Sex*
Patient Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Address (Billing Address)*
Same as Patient Address

Street Address City State / Province / Region ZIP / Postal Code Country
Price*
Price:
Total
$0.00
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

AVRT Consult Order Form

Let's begin your journey! Please complete the form below.

Care Oncology, Inc.A StageZero Life Sciences Company© 2022 All Rights Reserved

Care Oncology, Inc.
A StageZero Life Sciences Company© 2022 All Rights Reserved