CONSENT AND RELEASE
To agree to participate in this test, please review the above fact sheet and below bullets. Please provide the participant signature below indicating that the participant has read and understands these terms.
- I have read and understand the “Fact Sheet for Patients” provided to me- In consideration of my participation in this test, I hereby agree to assume all risks. I also understand the results are not designed to replace the care or advice of a medical provider. I understand that if I receive abnormal laboratory test results, I should promptly consult with a medical provider. - This test will not be billed to your insurance by HealthRidge Pharmacy. If requested, you will receive a receipt and invoice after testing to submit to insurance. Coverage is not guaranteed. Your insurance may reimburse the full amount, a portion of the amount, or none at all.
Please click one of the PayPal options to complete payment and submit the form.