Consent to release information

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1) SUBMITTING THIS FORM ELECTRONICALLY, AS WELL AS TYPING YOUR NAME AND CLICKING ON THE FINAL "SUBMIT" BUTTON AS YOUR ELECTRONIC SIGNATURE.2) ENTERING YOUR EMAIL ADDRESS, AND RECEIVING A COPY OF ALL OF YOUR RESPONSES AT THAT EMAIL ADDRESS. This allows us to insure that we connect the responses to this form with a valid person and address on the other side. *

I consent

Required

Name *

Email *

Date of Birth *

YYYY

Release Authorization *

I hereby authorize the Phuel Sports Science (Athlete Blood Test) to release health information about me.

Required

The following person/organization is hereby authorized to receive my laboratory report. Please include name and email address. *

By filling out this form and accepting the terms below, I recognize that electronic communication does not have any guarantee of privacy, and that a third party may be able to access my protected health information (PHI). However, due to the increased convenience offered by the use of methods such as online forms, email, text messages, and faxes, I consent to their use to transmit my PHI.Should I wish to withdraw my consent at any time, I understand that I must notify Athlete Blood Test in writing of the withdrawal of my consent. I will choose an option below consistent with the methods of communication I prefer. PLEASE CHOOSE AN OPTION BELOW: *

OPTION 1: I Consent to electronic transmission of my protected health information. I understand the risks of transmitting protected health information via non-secure methods and do hereby give permission to Athlete Blood Test to communicate with me and the party named above to transmit my protected health information via non-secure means including, but not limited to, email, online forms, online portal, and faxes.

OPTION 2: I DO NOT want my protected health information transmitted via email, online forms, portal, or faxes. I understand this means that I will not be able to send my lab results to to my dietitian.

Electronic Signature *

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