Name Date
Authorization for Release of Medical/Health Information
Patient Name
Date of Birth
I authorize DLS to release health information electronically (e-mail or fax) or paper to: Name of person or facility to receive health information
Street Address
City	State, Zip
Phone

Information to be released:
Laboratory Report(s) Date of Report:
Requisition Number:
Billing Statements:

Signature*: Date:
(Signature of Patient or Patient’s legal representative)
Printed Name:

*I hereby agree and acknowledge that I have read and consent to the terms and conditions of this Health Consultant Status form and that by my submission of this form via the About Your Body website I shall abide by its terms and agreements as if I had signed this document and delivered it in person, prior to my first consultation. I further agree that I shall either mail or hand deliver the original signature page to About Your Body indicating my true and accurate signature. ** If for some reason you have to cancel or postpone your appointment, you must give the office a 24 hour notice to fill your slot or you will be charged the full amount of the appointment.