BUPA medical visa services Pathology result request form BUPA medical visa services
Pathology result request form

Complete this form to request a copy of your BUPA medical visa service results. Please note that results are only available seven days after the date of service.

Customer details

First name

Last name

Date of birth

IME / HAP / UCI ID

Request details

Date of service

Declaration

I, the requester, declare the information I have provided on this form to be true. I understand that Healius will rely on this information to decide whether to deliver confidential health information. A false declaration by me may render me liable to civil or criminal prosecution under the Privacy Act 1988(Cth) or other Australian law.

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BUPA medical visa services Pathology result request form BUPA medical visa services Pathology result request form

Customer details

Title

Request details

Clinic state

Clinic

Declaration

BUPA medical visa services Pathology result request form BUPA medical visa services
Pathology result request form