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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.

 

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	Select... Outpatient Care CenterPalos Diagnostic CenterHalsted Medical CenterLittle Company of Mary HospitalLCM Burbank Medical Center
(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.	Yes No
CAPTCHA	Please type the text below