Patient Information

Please enter your information exactly as it appears on your identification.

Full Legal Name *

Date of birth *

Phone *

Email *

Address *

Street Address

City

State

Postal Code

Lab Draw | Preferred Blood Draw Location *

By checking this box, I consent to receive non-marketing text messages from WellnessMedX regarding my laboratory onboarding, appointment scheduling, blood draw instructions, service updates, and related care coordination. Message frequency varies. Message and data rates may apply. Reply STOP to opt out or HELP for assistance.

Terms & Conditions

Upload Your Photo Identification

Upload Driver’s License or Government-Issued Photo ID here *

Click to upload

PDF, PNG, JPEG or JPG ( max 1 Files )Please upload a clear image of the front of your valid driver’s license or government-issued photo ID. Make sure your name, photograph, and identifying information are visible and readable.

What to Expect - Blood Draw Information

Please review the scheduling, blood draw preparation, results, and payment information before continuing.

Welcome Call & Scheduling

Our team will contact you within 1–2 business days to welcome you to WellnessMedX and coordinate your blood draw appointment.

Choose Your Draw Location

You may complete your blood draw at our WellnessMedX Santa Clarita clinic or at an available partner laboratory location. Partner laboratory locations are available throughout all 50 states.

Prepare for a Morning, Fasted Draw

Please do not eat after 9:00 PM the evening before your appointment and do not eat the morning of your blood draw. Your blood draw will be scheduled before 9:30 AM to support evaluation of morning cortisol levels.

Results & Provider Consultation

Laboratory results generally become available within approximately five business days. Once your results are ready, our team will contact you to schedule a consultation with one of our providers.

Laboratory Cost & Payment

The self-pay cost of the general wellness laboratory panel is $350. If your blood draw is completed at the WellnessMedX Santa Clarita clinic, you may pay on the morning of your appointment. If you are completing your blood draw at an outside partner laboratory location, our team will send you an invoice link before scheduling your draw.

Testing Information Acknowledgment *

I confirm that I have reviewed and understand the blood draw preparation, scheduling process, testing location options, expected results timeline, and payment information provided above.

Review, Consent & Sign

Review the consent, acknowledge it, and provide your electronic signature.

Functional Laboratory Testing Informed Consent

Purpose of Functional Laboratory Testing

Functional laboratory testing may be used to assess physiological function, nutritional status, hormone balance, gut health, and other health-related markers that may not be fully evaluated through conventional testing. These tests are intended to provide a more comprehensive view of health and help guide personalized care recommendations.

Nature of Testing

I understand that:

• Functional laboratory testing may include blood, saliva, urine, and/or stool samples.

• Testing may be processed by specialized laboratories that may not participate in standard insurance networks.

• If I choose to use insurance for qualifying tests, I understand that I am responsible for any resulting patient responsibility, balance, or invoice. Estimated costs may range from $2,500 to $3,500.

• The self-pay option for the General Wellness Panel is $350.

Potential Benefits

• Testing may help identify imbalances or factors that may be contributing to symptoms.

• Results may provide additional information to support personalized nutrition, lifestyle, wellness, and care recommendations.

• Testing may support a more proactive and preventive approach to health and wellness.

Limitations

I acknowledge that:

• Functional laboratory testing is not intended to diagnose, treat, cure, or prevent any disease on its own.

• Results may not be recognized or interpreted in the same way by all healthcare providers.

• Interpretation of laboratory results may vary among practitioners.

• No guarantees are made regarding outcomes, symptom improvement, or changes in health.

Financial Responsibility

I understand that:

• Many functional laboratory tests may not be covered by insurance.

• I am responsible for the applicable cost of testing, including any associated laboratory, shipping, collection, or processing fees.

• Payment policies have been explained to me, and I agree to the applicable financial terms.

Risks and Discomforts

• Blood draws may cause temporary discomfort, bruising, bleeding, lightheadedness, or, in rare cases, other complications.

• Collection of stool, saliva, or urine samples may be inconvenient or uncomfortable.

• There is a minimal risk of error during sample collection, handling, transportation, or processing.

Confidentiality

Laboratory results and related health information will be handled according to applicable privacy requirements. Results may be shared with other healthcare providers or authorized individuals when permitted by the patient or otherwise allowed by law.

Voluntary Participation

I understand that:

• Participation in functional laboratory testing is voluntary.

• I may decline testing before specimen collection without affecting my ability to seek other available care.

Acknowledgment and Consent

By signing below, I confirm that:

• I have read and understand the information provided above.

• I have had the opportunity to ask questions and receive answers.

• I voluntarily consent to functional laboratory testing as recommended.

Optional Release of Laboratory Results

I would like to authorize WellnessMedX to release my laboratory results to another individual or healthcare provider.

Release Recipient Name *

Organization

Relationship *

Release Recipient's Phone

Release Recipient's Email

Consent Acknowledgment *

I confirm that I have read and understand the Functional Laboratory Testing Informed Consent above. I have had the opportunity to ask questions and receive answers. I voluntarily consent to functional laboratory testing as recommended.

Patient Electronic Signature *

Clear

By signing, I confirm that this is my electronic signature and that I intend to sign and agree to the Functional Laboratory Testing Informed Consent above.