Your Results, Faxed Directly to Your Physician

If you would like to share your biometric screening results with your physician, please complete the following authorization form. Please be sure to complete ALL fields:

Complete the following:

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Fax Authorization Agreement:

I hereby authorize WellnessFX, Inc. ("WellnessFX") To send my laboratory test results to the provided fax number, which I represent as secure and safe for WellnessFX to use to send such test results. I assume risk from transmission by WellnessFX of my laboratory test results to this fax number. I understand that these test results will have my name and other identifying information on them, and will contain my personal and sensitive health information. 



Phone: (855) 241-5585

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