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

First Name *

Last Name *

Date of birth *

Phone *

I authorize Evernine Diagnostics to email my drug testing results to the address I provide below and agree to notify the clinic if my contact information changes. I understand that any information disclosed by email is subject to re-disclosure under this authorization.

Email *

I authorize Evernine Diagnostics to send my drug testing results to the email address I’ve provided for this visit only. A new authorization is required for each future visit. I may revoke this consent at any time by submitting a written request in person or by mail. I understand that Evernine Wellness & Diagnostics cannot control access to my personal email account and that once results are sent, they may no longer be protected by HIPAA.

Sell Products *

OralTox™ 10 - Panel Saliva Drug Test

$49

Signature *

Clear

By checking this box, I consent to receive service-related communications about my account or appointments. These may include reminders, confirmations, and notifications. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive wellness updates and promotional messages, including offers, discounts, and new service announcements. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

Where did you hear about us? *

Other (please specify)