Online Medical Consent Form
Patient Information
Name
Age
Date of Birth
-
Month
-
Day
Year
Gender
Please Select
Male
Female
Email
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Click here
Health Insurance Name
Insurance Policy ID
*
Insurance Package/Type
Please take a photo of your insurance card
Primary Insured Name and Date of Birth
Parent/Guardian or Emergency Contact Details
Contact Person Name
Primary Phone Number
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Area Code
Phone Number
Secondary Phone Number
-
Area Code
Phone Number
Click here to upload a picture of your physician's order
Acknowledgment, Authorization and Waiver
I authorize Lab Worxx to perform the treatment or necessary procedure to me/ or to my (for Parent/Guardian) dependent.
I confirm that the doctors explained the procedure thoroughly to me and how it will help me with my current condition.
I authorize Lab Worxx to release my results to my ordering physician.
I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves post-treatment and follow-ups.
I authorize Lab Worxx to bill my insurance.
Patient/Parent/Guardian Signature
Clear
Submit
Date Signed
-
Month
-
Day
Year
Should be Empty: