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NAME / BIRTH DATE:
EMAIL / ADDRESS / PHONE:
EVER BEEN DRAWN FOR MNT BEFORE?
Yes
No
Male
Female
By signing below, I acknowledge: 1) No test other than the specific test(s) ordered shall be performed on the biological sample. 2) The information in the patient information is accurate, and I give SpectraCell Labs consent to release results to the email address listed in the patient information section and to Danbar for Life when applicable.
PATIENT SIGNATURE:
Erase Signature