Pharmacy Testing Form

Section - Form Consent
Consent
- I acknowledge that all information I entered in this form is accurate and true.
- I authorize this facility to collect a sample specimen for me in order to perform this test.
- I release the facility and all of its employees and affiliates, from any liabilities, damage, or accidents related to this testing activity.
- I authorize this facility to share with the requester (e.g., company) my health care information, including diagnostic test results and medical test results.
- I understand that this diagnostic test is for informational purposes only. This facility will not admit patients or provide medical advice.
I acknowledge and give consent for this test request.*

Yes
Submission Date

MonthDayYear
Date
Please verify that you are human*
Signature*

Clear
Should be Empty:

Testing Options