If you are filling this form out for a minor, click here: Blood Test Authorization Form Minor 

 

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Blood Test Authorization Form

Blood Test Authorization Form

Please fill out the fields below pertaining to the corresponding fields above in the Customer Blood Test Authorization Form. By filling this information out and signing it, you are giving Health Restored permission to complete and submit this form to Life Extension on your behalf.

Please check all of the following that apply (if anything other than the pre-selected options apply to you, please contact us at 719-481-4594 or office@healthrestored.com to complete your authorization)
Delivery Method: Choose how you want to receive your blood test (if anything other than the pre-selected options apply to you, please contact us at 719-481-4594 or office@healthrestored.com to complete your authorization)
Sex: *