Client Portal Access Request

Please complete the following Client Portal Access Request form in its entirety. Do not leave any items blank. After you have submitted a completed request form, a Health Network Laboratories representative will contact you and assist you with access to the Healthcare Professional Portal.

Client ID:
Client Name:
Street Address:
City, State Zip	,
Contact Person:
Phone:
Requested Access:	Order Supplies Connectivity Solutions: Electronic Orders or Results
Comments: