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)

I will use a LabCorp blood draw station

I will not use a LabCorp facility and I require a blood draw kit

I am having my blood drawn in Massachusetts, New York, New Jersey, or Rhode Island. I require a blood draw kit so that I can get my blood dwarn at any lab that drawas blood (an additional local blood draw fee may be incurred). Blood tests not available in Maryland.

I am having my blood drawn AND I am ordering a frozen blood test that requires a cooler (additional charge applies, please see reverse side for instructions)

I authorize Life Extension to send my test results directly to my health practitioner or Life Extension wholesaler who ordered the tests. E-mail or fax to: Office@healthrestored.com

I authorize Life Extension to review my results with me. Call me at ______________

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)

Email: office@healthrestored.com

I authorize Life Extension to send my blood to Health Restored AND my email as entered below

Fax: _______________________

Standard Shipping (via USPS First-Class Mail, no additional charge)

UPS Overnight (add $16)

USPS 2nd Day (add $7)

Customer Name (print): (First/Middle/Last) *

Customer Address: *

City/State/Zip-Postal Code: *

SHIP TO Address: (If different from above)

City/State/Zip-Postal Code: (If different from above)

Phone: *

Date of Birth *

Sex: *

Male

Female

Signature *

Clear

Date *