MINOR CONSENT AND RELEASE FORM FOR LABORATORY HEALTH SCREENING

As the parent or legal guardian of the minor named on the form, I consent to the recommended lab screening tests facilitated by a licensed healthcare provider as part of a wellness protocol recommended by my health coach. The tests will be ordered by a licensed healthcare provider, and I understand that my health coach will offer interpretation and guidance based on the results to support my dependent’s health goals.

1. Test Explanation & Risks

If you ordered a blood test, taking a small blood sample carries minimal risks such as dizziness or fainting. Please ask questions if needed.

2. Confidentiality

Your dependent’s personal information will be used only for necessary follow-up. It will be kept private and protected by applicable laws. Consent can be revoked at any time by written request.

3. Participant Responsibilities

By consenting, you acknowledge that the lab test is a supportive measure in your dependent’s wellness plan. You understand that interpretation and coaching are intended to provide guidance and are not substitutes for medical treatment. You are encouraged to consult with a healthcare professional regarding any results or additional medical needs. You are responsible for seeking medical advice if there are any abnormal results.

4. Release of Liability

You accept all risks of the screening and release me (the health coach) and any facilitating healthcare providers from liability related to participation or results.

5. Consent Confirmation

You have read and understood this form and voluntarily consent to the lab screening for your dependent. Please sign below to proceed.