Copy of a lost requisition

  • Once your request below is completed, we will be happy to respond to your request within 15 business days if your doctor is not absent (on vacation, congress or other).

    The copy of a lost requisition is not a service covered by Medicare. Therefore, fees apply, based on the Federation of Physicians' fee scale.


    Please remember to check your ''spam'' or ''junk'' folder if you do not receive a response from us within 15 business days.  

  • AAAA slash MM slash JJ
  • (No space)
  • MM slash JJ slash AAAA
  • Prix:
  • Prix: $ 0.00 CAD
  • Prix: $ 0.00 CAD
  • $ 0.00 CAD
  • (You will receive a copy of your request via a highly secure email. You will need to enter the password you chose in order to access your file.)
  • AlbertaColombie-BritanniqueManitobaNouveau-BrunswickTerre-Neuve-et-LabradorTerritoires du Nord-OuestNouvelle-ÉcosseNunavutOntarioÎle du Prince-ÉdouardQuébecSaskatchewanYukon
  • MasterCard
    Visa
    Cartes bancaires prises en charge : MasterCard, Visa
    Mois010203040506070809101112 Année20232024202520262027202820292030203120322033203420352036203720382039204020412042  
  • Secure payment via PayPal
  • After clicking on the ''submit'' button, please do not exit this page before being redirected to the confirmation page.

gform.initializeOnLoaded( function() {gformInitSpinner( 52, 'https://www.physimed.com/wp-content/plugins/gravityforms/images/spinner.svg' );jQuery('#gform_ajax_frame_52').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_52');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_52').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_52').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_52').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_52').removeClass('gform_validation_error');}setTimeout( function() { /* delay the scroll by 50 milliseconds to fix a bug in chrome */ jQuery(document).scrollTop(jQuery('#gform_wrapper_52').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_52').val();gformInitSpinner( 52, 'https://www.physimed.com/wp-content/plugins/gravityforms/images/spinner.svg' );jQuery(document).trigger('gform_page_loaded', [52, current_page]);window['gf_submitting_52'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}setTimeout(function(){jQuery('#gform_wrapper_52').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_52').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [52]);window['gf_submitting_52'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_52').text());}, 50);}else{jQuery('#gform_52').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger('gform_post_render', [52, current_page]);} );} );
0 réponses

Répondre

Want to join the discussion?
Feel free to contribute!

Laisser un commentaire

Votre adresse e-mail ne sera pas publiée. Les champs obligatoires sont indiqués avec *