Schedule a Test

Schedule a Test

Online Test and Screening Scheduling

Here you can schedule a test or screening at Little Company of Mary Hospital and Healthcare Centers. Complete the form below and indicate in the message what test or screening you would like to schedule. After submitting your form, you will receive a phone call confirming your appointment.  Some payers require additional information.

 

Please download the forms below, fill them out, and bring them with you to your next appointment.

 

For Medicare Patients Only

Privacy Notice (English)*

Privacy Notice (Spanish)*

Financial Responsibility Form (English)

Financial Responsibility Form (Spanish)



 * To view LCM Notice of Privacy Notice Acknowledgement (English)

 * To view LCM Notice of Privacy Notice Acknowledgement (Spanish)

Required fields are marked with a

First Name

 

Last Name

 

Address

 

City

 

State

 

Zip

 

Telephone

 

Date Of Birth (mm/dd/yyyy)

 

Email Address

 

Type of Test


Characters remaining:
 

Ordering Physician

Diagnosis

Facility Preferred

(not all tests are performed
at each facility)

Type of Insurance

Insurance ID Number

Insurance Group Number

Message


Characters remaining:
 

I'd like to join the Little Company of Mary elist.

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