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Upload Lab Results

Please upload your lab results using the form below

The Records Release Form expires every 90 days. If it has been 90 days or more since you last completed this form, please fill out a new one below.

New/Returning Patient - Records Release

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This field is for validation purposes and should be left unchanged.
- Patient's Name*
- E-mail*
- Phone**
- Date of Birth*
  MM slash DD slash YYYY
- - I request and authorize the following healthcare providers to release healthcare information of the patient named above to BioIntelligent Wellness, 7220 Avenida Encinas, Suite 110-B Carlsbad, CA 92011 (Phone: 858-228-3644 / Fax: 858-228-3641
- I have a provider
  - I have a provider
- Provider’s name**
- Provider’s address**
- Provider’s phone**
- Add provider*
Definition
- Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human papilloma virus, wart, genital wart, condyloma, Chlamydia, non specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea.
- I authorize and understand
- I authorize and understand
  - The release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s) listed above.
  - That the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.
  - The release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed here.
By submitting this form, you agree to our Privacy Policy and Terms of Use and consent to receive occasional messages from BioIntelligent Wellness.

By providing your phone number, you agree to receive informational text messages from BioIntelligent Wellness. Consent is not a condition of purchase. Message frequency will vary. Msg & data rates may apply. Reply HELP for help or STOP to cancel.
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CONTACT

Name
This field is for validation purposes and should be left unchanged.
First Name*
Last Name*
Phone*
E-mail*
Program you're interested in*
Message*
By submitting this form, you agree to our Privacy Policy and Terms of Use and consent to receive occasional messages from BioIntelligent Wellness.

By providing your phone number, you agree to receive informational text messages from BioIntelligent Wellness. Consent is not a condition of purchase. Message frequency will vary. Msg & data rates may apply. Reply HELP for help or STOP to cancel.
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Upload Lab Results

Please upload your lab results using the form below

New/Returning Patient - Records Release

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Upload Lab Results

Please upload your lab results using the form below

New/Returning Patient - Records Release

CONTACT

Ready to get started or have a few more questions?

Still have a few more questions?

Ready to get started
or have a few more questions?