Patient Intake Form

Patient Intake Form

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  • Patient Intake Form

    First Name

    Last Name

    Phone Number

    Date of Birth

    Email

    Your Address

    City

    Apt

    Zip Code

    State

    May we contact you at this number?

    May we contact you at this email address?

    May we forward laboratory results to this email address?

    I hereby certify that the answers given by me to the above questions are true and complete to the best of my knowledge and I have read and understand them. I have had an opportunity to ask questions that were answered to my satisfaction and wish to receive Services.

    Furthermore, I hereby release and forever discharge for myself, my heirs, executors, administrators and assignees, 24/7 Labs and their employees, owners and representatives, from any and all claims, demands, actions and causes of action which may or could result from your.
    Declaration

    Your personal information and any results shall be held strictly confidential. I understand that 24/7 Labs is not a Medicare or Medicaid participating provider. Insurance will not be billed; however, forms and receipts may be made available to me in order for me to request possible reimbursement from any other third party. Third parties include, but are not limited to, insurance companies, employers or other entities that may provide benefits for any type of healthcare reimbursement.

    By Clicking on Submit you agree to all the declarations and policies of the company as has bene mentioned on the website,
    Sign here


    1. I understand that 24-7Lab testing is acting in the role of a 'collection facility' and will not interpret the results of any testing for which a collection of either hair, blood or urine is obtained. I am using the services of 24-7Lab Testing simply to perform a collection of hair, blood or urine. I understand that neither 24-7Lab Testing nor its ordering physician will analyze, evaluate, critique, review or otherwise interpret the results of said tests. I agree that 24-7Lab Testing, it's officers, shareholders, directors, employees, physicians, or its agent shall not be liable for any claims including, but not limited to, any claim arising out of or related to, inaccurate, un-interpreted, misinterpreted or results not received and do hereby expressly forever release and discharge all claims, demands, injuries, damage, actions or causes of action.


    2. I agree that I am personally financially responsible for payment of fees for all draw fees for tests ordered and collected by 24-7Lab Testing at my request. I also agree that I am personally responsible for the accuracy of all personal information, including any insurance information, for any draw service for which I am seeking reimbursement. I agree to not hold 24-7Lab Testing or any of its officer, owners, directors or employees responsible for proper completion of any personal information which may be required by the lab or the entity which will actually perform the test. I further agree that the payment of any laboratory fees which may include, but are not limited to administrative, testing, handling or shipping are my sole responsibility, and I discharge 24-7Lab Testing from any financial responsibility for payment to any lab for services that I may receive.


    3. I have read and understand the draw instructions and have had the opportunity to ask any questions about the nature of the collection performed by 24-7Lab Testing. I understand that I as the donor am responsible for any collection requirements, and I have taken the necessary steps to ensure that I am in compliance with these requirements. I understand that 24-7Lab Testing will not provide a refund or any type in the event that my specimen should be considered by the testing laboratory to be out of compliance. I understand, that in some cases, it is my responsibility to prepare for the draw in advance, by either fasting or specimen preparation, and I discharge 24-7Lab Testing from any responsibility related to preparation of specimens that may not be properly prepared by myself, prior to arrival.


    4. I understand and agree that the services provided by 24-7Lab Testing are considered as protected health information by 24-7Lab Testing as required by federal and state law.


    5. I understand that the test results may become part of my medical record. I also understand that an insurance company may discover the results of this testing by obtaining a copy of my medical record in accordance with the terms of my insurance policy or policies.


    24/7Labs would like to contact you about products, services and offers that may interest you. By marking this statement, you indicate your consent to receive marketing communications by post, phone, email, text and other electronic means, if you do not wish to receive such communications, do not mark this statement.