You can always press Enter⏎ to continue
Medialpha Homepage form EN
1
Which service are you looking for?
*
This field is required.
Medication injection - 60$
Wound care - 60$ for 15 min, 20$ per additional 15min
Strep test - 60$
Chemstrip (Urinary tract infection ) - 60$
Public blood test - 90$
Private blood test - variable cost
Telemedicine - variable cost
Back
NExt
Submit
Press
Enter
2
What date would you like to receive the service?
-
Date
Year
Month
Day
Back
NExt
Submit
Press
Enter
3
Do you private insurance?
*
This field is required.
Yes, it is cover
No, I don't have a coverage
I don't know
Yes, it is cover
No, I don't have a coverage
I don't know
Back
NExt
Submit
Press
Enter
4
What is your postal code?
*
This field is required.
Back
NExt
Submit
Press
Enter
5
Last name, first name and contact number
*
This field is required.
Last name
First name
Phone number
Back
NExt
Submit
Press
Enter
6
Your email
*
This field is required.
example@example.com
Back
NExt
Submit
Press
Enter
7
Do you have a requisition ?
*
This field is required.
A requisition will help us match you faster with a nurse.
YES
NO
Back
NExt
Submit
Press
Enter
8
Upload your requisition
*
This field is required.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Requisition
Cancel
of
Back
NExt
Submit
Press
Enter
9
Do you have any questions? Ask us here.
Back
NExt
Submit
Press
Enter
10
Does your medical insurance cover your laboratory analysis?
Optional
Yes, it is covered
I don't have medical insurance
I don't know
Back
NExt
Submit
Press
Enter
11
Check the following box.
*
This field is required.
Back
NExt
Submit
Press
Enter
Should be Empty:
Question Label
1
of
11
See All
Go Back
Submit