For the year of 2024, I hereby voluntarily give permission that my blood be drawn or that I receive a B12 injection, or have a nasal swab test performed or urine sample collected from me. I understand and take full responsibility that there may be risks from having my blood drawn, having a nasal swab performed, or receiving an injection including:

Discomfort at the site of needle insertion, pain or bruising at the site of needle insertion, possible lightheadedness or fainting, and on rare occasions infection, along with other unforeseeable risks.

Discomfort in the nose and nasal cavity, nose bleeds, and on rare occasions infection, along with other unforeseeable risks.

If getting a B12 shot: I declare to have no known allergies that would prevent me from receiving an injection.

I understand that on a rare occasion a recollection of specimen may be needed at no cost. This would be due to not enough sample collected to be tested, specimen stability, and routing issue of the courier.

I understand that the results or date collected from any labs or tests done on my sample are merely informational, and do not constitute a diagnosis, prognosis, or other medical conclusion or advice of any sort from Be Well Lab Services.

I understand that it is my responsibility to initiate a conversation or follow-up with a medical professional regarding interpretation, analysis, evaluation, and explanation of the results of my labs tests, and that Be Well Lab Services will not be responsible for my failure to do so.

I certify that I can seek to be reimbursed by my insurance carrier, Medicare or Medicaid, Tricare or any other government insurer/payer on my own and that Be Well Lab Services is a self-pay facility and will not seek reimbursement or guarantee reimbursement for me. I agree that I am personally financially responsible for payment of fees for all tests ordered and collected by Be Well Lab Services.

Be Well Lab Services will keep my results confidential, according to privacy laws and will only be released to the ordering physician or care provider of my choice. Be Well Lab Services will not provide information to other organizations without my consent. If my employer/provider is requiring me to receive this test or service, I consent for the results to be released to my employer.

I give consent for Be Well Lab Services to send correspondence by via text, email, or the mailing address that you provided on this form.

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