Rupa Health Service Request

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Our skilled Specialists and staff will strive to make your appointment an excellent

Patient First Name*

Patient Last Name*

Birthday:

Email Address*

Clinic / Provider Info:

Appointment Date (Preferred)*

Appointment Date (2nd Choice)

Preferred Time

Preferred Time (2nd Choice)

Do you have lab kit on hand?

YES

NO

Lab Kit Name

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I accept terms & conditions: Policy Terms When scheduling your appointment request, please note that this booking is not the official confirmation. One of our customer care team members will give you a call within 24/48 hours. *Extra Lab Kits will incur an additional fee. Please note that all invoices are to be paid upon receiving the invoice. UWP will not hold your appointment slot if payment is not received within 48hrs of receiving your invoice. You will then have to reschedule your appointment. We can not guarantee that the original time/date will be available if you miss payment. Please note, there will be no refunds on patient no shows and on any service rendered.

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