New Customer Kit Registration/Intake Form

New Customer Kit Registration
Patient's Full Name*

First NameLast Name
Date of Birth *

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
E-mail Address*
example@example.com
Unique ID*
This will automatically populate after scanning QR code. If registering from the website contact us via email at customerservice@gotluckylabs.com or call +1 (805) 576 - 8288

HIPAA Data Release Consent
At Got Lucky Labs, we are committed to protecting your personal health information in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This notice describes how your medical information may be used and disclosed, and how you can access this information.

We may use your health data to provide testing services, share results with our partner laboratories or authorized healthcare professionals, and comply with legal or public health obligations. We do not sell your personal data. You have the right to request a copy of your records, limit certain disclosures, and revoke your consent at any time. To review the full details of your privacy rights and our responsibilities, please refer to our complete Notice of Privacy Practices or contact us at privacy@gotluckylabs.com.
Consent for services, testing, and privacy policy
I have received and acknowledge the [Privacy Practices].
I understand and consent to the testing process, its risks, and my rights.
I consent to receive services, including remote Telehealth care where applicable.
I may revoke this consent at any time by contacting privacy@gotluckylabs.com
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New Customer Kit Registration