Online Medical Consent Form
Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Health Insurance Name
Insurance Policy ID
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
Secondary 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.
Should be Empty: