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YOUR DESTINATION MAY REQUIRE A NEGATIVE COVID-19 RT-PCR TEST

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SCHEDULE A LAB TEST APPOINTMENT IN
Fort Worth, TX 76131

TESTS SELECTED

You can select up to 10 tests per appointment

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Your appointment details

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at Any Lab Test Now®
Fort Worth
2700 Western Center Blvd., Suite 100
Fort Worth, TX 76131
CHANGE LOCATION

Contact Information

To better serve you, we need to know the name of the person taking the test.

Conditions

Thank you for requesting an appointment

to have lab work done at Any Lab Test Now®
2700 Western Center Blvd., Suite 100, Fort Worth, TX, 76131

We are grateful for this opportunity to provide excellent service and information about the testing services we offer!

You can decide to get additional tests when you come in for your appointment.

Whether for clinical, employment related, DNA or for self-care health management, our caring professional staff will ensure that your visit is pleasant and comfortable.

If you are requesting an appointment that is less than 2 hours before store closing, please call (817) 349-0991 to confirm that there will be ample time for specimen collection and test processing.

To keep our prices transparent, no insurance is accepted. Self-pay and HSA (Health Savings Accounts) are your available payment options.

Sincerely,

ANY LAB TEST NOW® Fort Worth (817) 349-0991

Consents

In order to expedite the process leading to the test, it is essential to fill the following forms:

Consent Authorization

To expedite the process for your test, please answer the following questions.
**Typing your name will represent your signature.

By signing this form, I confirm that I am authorized to give consent to ANY LAB TEST NOW® to perform the tests and agreed to all terms. **
THE CUSTOMER TAKING THIS TEST WILL BE REQUIRED TO FILL OUT CONSENT FORMS BEFORE SERVICES ARE PROVIDED. PLEASE ALLOW 10 MINUTES BEFORE THE APPOINTMENT.

Customer authorization for disclosure of protected health information via e-mail

Please review the details below and confirm by entering your name in the customer signature field.
I, the undersigned, authorize ANY LAB TEST NOW® to disclose or provide protected health information (laboratory results only) directly to me at the e-mail address I have provided below. I also understand that it is my responsibility to notify ANY LAB TEST NOW® of any change in this information. Any disclosure on e-mail is subject to the re-disclosure statement within this authorization.

I authorize ANY LAB TEST NOW!® to disclose the protected health information, my lab results, to the e-mail address I have indicated. This authorization is only effective for the visit date ("Today's Date") listed on this authorization form. You must submit a new authorization at each visit to ANY LAB TEST NOW® if you wish to have laboratory results sent to you by e-mail.

As stated in our Notice of Privacy Practice, I have the right to revoke or terminate this authorization by submitting a written request to the facility. This can be done in person or by mailing a request to the testing ANY LAB TEST NOW®.

RE-DISCLOSURE

I understand that ANY LAB TEST NOW® has no control over who may have access to the e-mail address I have listed to receive my protected health information.
The information disclosed will no longer be protected by the requirements of the Privacy Rule and future discloser is not responsibility of ANY LAB TEST NOW®.
Typing your name will represent your signature

General Intake Consent

Customer Authorization for Disclosure of Protected Health Information via e-mail.
Optional
Typing your name will represent your signature

Thank you for your interest in buying these test(s) for your child under the age of 12.

Because of the special nature of working with children, we ask that you contact our store to provide us with additional details regarding the test(s) you are seeking for this underage customer.

Thank you and we look forward to serving you!

THANK YOU FOR SCHEDULING YOUR APPOINTMENT. YOU CAN PAY NOW AND SAVE TIME OR PAY AT THE TIME OF SERVICE.

Thank you for your interest in making an appointment for your child under the age of 12.

Because of the special nature of working with children, we ask that you contact our store to provide us with additional details regarding the test(s) you are seeking for this underage customer.

Thank you and we look forward to serving you!

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CONTACTLESS PAYMENT REQUIRED

For the safety of our customers and employees, this test requires advance payment to confirm your appointment.


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