AUTHORIZATION TO PERFORM TESTS

AUTHORIZATION TO PERFORM TESTS

Please complete this form in its entirety.
I authorize Dr. Ronald Blatt, Manhattan Center for Gynecology and/or his associates to perform the following test(s). *

Pap Smear / Thin Prep HPV GC / Chlamydia Vaginal Culture Blood Test(s) Ultrasound Other
I have been informed and I understand that I will be billed separately by the laboratory. If I do not have insurance or if my insurance does not cover any of these tests, I acknowledge that I am solely responsible for satisfying payment of those fees.

I have been advised to contact this office for test results in 10-12 working days. Please note that all patients must come back into the office for consultation for abnormal labs, STD testing and HIV test results.
Full Name *

First Name Last Name
Today's Date *

Month Day Year
Date
Email *

Confirmation Email example@example.com
Patient Signature *

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