Result Release Form

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Crawford’s Blood Work
RESULT RELEASE FORM
By signing this Release Form I am authorizing Crawford’s Blood Work and/or USA Blood Work to include my
test results, and any past/future test results, in their database for review by Athletic Commissions. (Results
will only be available if tests are negative.)
/_____/______
Name,__________________________________________________ Date of Birth _____
Please Print
mm /
dd
/
yyyy
Signature, ________________________________________________Today's Date _____/ _____/ ______
mm /
dd / yyyy
If you also wish us to fax your test results please provide the following information:
Testing Date _____/_____ (month/year).
While I understand that Crawford’s Blood Work and/or USA Blood Work do not encourage the use of faxing
or Emailing as a routine reporting method of confidential results, I request the use of faxing or emailing my
results to the number listed below. I certify that the fax number or email listed below is in a secure area and
is accessible to me.
I take responsibility for retrieving the results and agree to defend, indemnify, and hold Crawford’s Blood
Work and/or USA Blood Work wholly harmless from and against all costs (including reasonable attorney's
fees), liabilities, and expenses arising out of wrongful disclosure, breach of confidentiality of the misuse of
my information.
Please Fax or Email results to (#): 1-702-924-0770
Email:
Attn: Medlic, LLC
Please call C rawford’s Blood Work
To set up your Blood Work today for only $80!
9:00am to 10:00pm Central time
816-728-7360
****Please send a copy of your photo ID****
5430 Douglas Ave, Kansas City, KS 66106 - 1-816·728-7360
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