Order and Testing Consent

Order and Testing Consent
Thank you for purchasing a Longevity Diagnostics Health Test Panel. To complete your purchase, please fill in the Client Information below; then, read and accept the Privacy and Terms of Service Statements and submit the payment details. Your payment will be processed when the consent form has been submitted.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Client Information
Name
Email

Confirmation EmailConfirm Email Address
Telephone Number
Format: (000) 000-0000.
Telephone Type
Address

Street Address

Street Address Line 2 (Apt/Unit/Building)

CityState

Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Acknowledgment, Authorization and Waiver
Please authorize the laboratory testing by agreeing to the following statements:

I understand that the answers I provide to Longevity Diagnostics on the Health Questionnaire will be protected health information and used confidentially to assess my current health status more accurately, determine my risk for major diseases like cardiovascular disease and dementia, and inform the nutrition and lifestyle coaching session and/or medical consultation that may be included with my purchase.I understand, if I am purchasing the Standard or Advanced Health Test, that my purchase includes a 30-minute, one-on-one teleconference with a nutrition and lifestyle coach who is a registered dietitian, which I will schedule when I receive my test results. If I am purchasing the Longevity Advanced Health Test, I will also be able to schedule a 15-minute, one-on-one medical consultation with a licensed healthcare professional.
Client Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Payment

Select One of the Following Test Panels

Longevity Standard Test Panel

27 lab tests with 30-minute nutrition and lifestyle coaching teleconference

$249.00 Quantity

Longevity Advanced Test Panel

37 lab tests with 30-minute nutrition and lifestyle coaching teleconference and 15-minute medical consultation (Includes Longevity Standard Test Panel)

$549.00 Quantity

Longevity Genetics Test Panel

8 tests for genetic variants associated with cardiovascular disease and dementia risk and response to certain medications

$249.00 Quantity

Longevity Advanced Plus Test Panel

45 chemistry and genetic tests with 30-minute nutrition and lifestyle coaching teleconference and 15-minute medical consultation.

Combines Longevity Advanced and Longevity Genetics Test Panels

$699.00 Quantity

Total

Payment Methods
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Should be Empty:

Order and Testing Consent

Client Information

Acknowledgment, Authorization and Waiver

Payment

Select One of the Following Test Panels*

Select One of the Following Test Panels