Liver STAT Registration
  • Liver STAT Registration

    Services provided on a non-discriminatory basis.
  • Format: (000) 000-0000.
  • Ethnicity*
  • Preferred Written Language*
  • Please select the option(s) that qualify you for participation in the program.*
  • Appointment Date and Time*
  • RELEASE: I hereby authorize the drawing of a blood sample for the purpose of measuring 7 biomarkers and 4 anthropometrics for the purpose of using algorithm technology to determine the fibrosis, activity, and steatosis stages of my liver. My medical information and test results will be treated as confidential information in accordance with applicable Federal and State statutes, rules, and regulations. Appropriate American Liver Foundation and Links2Labs staff and representatives may review my records and information to verify the information collected and/or to provide information about additional treatment and providers that may be available to you. I have read, understood, and been given the opportunity to ask questions regarding this program & received a copy of this consent form. All of my questions have been satisfactorily answered and I do not have additional questions. I realize that the data obtained may be used in print, presentations, media, or grants but my name/contact information will never be used. I may revoke this consent in writing except that it shall not affect information that has previously been disclosed under this consent. Furthermore, I hereby release and forever discharge for myself, my heirs, executors, administrators and assignees, The American Liver Foundation and their past/current employees, past/current directors and past/current representatives and the lab partner, Links2Labs, from any and all claims, demands, actions and causes of action, which may result from participation in this program. By signing this consent form, I agree to be contacted by The American Liver Foundation for education and support services.

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