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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.

- 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, 124 Lomas Santa Fe Drive, Suite 206, Solana Beach, CA, 92075 (Phone: 858-228-3644 / Fax: 760-994-1248
- 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.
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