Laboratory Test Results Release Form

Hydrations LLC - Lab Services

Champaign, Arthur, Bradley

10a-5p Tues&Thurs - Champaign
8a-10a Saturdays - Bradley
11a-4p 1st & 3rd Mondays - Arthur

First Name

Last Name

Date of Birth

Street Address

City, State

Zip Code

Phone #

Email address

Did you FAST for your tests today?

Yes

Please select one method for receiving your testing results

Electronic Mail

Hydrations LLC uses a HIPAA complient email service to send your results. Your results will be sent to the email address entered above.

Mail (USPS)

Results sent by mail are typically received within 10 business days from the date of testing. Your results will be mailed to the address entered above.

Fax

You authorize us to send your results via Fax to the following

Pickup

ID verification will be required

Fax Number

Recipient Name

Relationship

Authorized Person

Relationship

Authorization and Consent

By submitting this form:

I authorize Hydrations LLC to perform health testing as part of their wellness screening program.
I understand that in no way does Hydrations LLC propose, diagnose, recommend or provide medical treatment.
I understand that it is my sole responsibility to contact a physician to follow up with my test results.
I relieve Hydrations LLC, it's employees and it's partnering businesses and their employees from any liabilities relating to the confidentiality of my personal data or test results.
I authorize Hydrations LLC to release my test results using the method I have selected above.
I Authorize Hydrations LLC to release my test results to the person I have authorized above.

Your information will be encrypted.