Patient Consent for Lab Ordering

Welcome to Rupa Health! We're excited to have you.

Authorization

By filling this out, you consent to the Rupa Health team contacting you about labwork ordered by your provider. We will contact you via email to collect and invoice for labs, and act as your point of contact for any questions around completing the labs. The Rupa Health team may also communicate with your practitioner about lab-work ordered for you.

For any questions, contact support@rupahealth.com.

I authorize the Rupa Health Team to order and handle lab work on behalf of my provider and communicate with me via email regarding my health information. *

Your Information

This information is used to auto-populate your lab requisition forms.

• First Name *
• Last Name *
• Email Address *
• Gender *Select...FemaleMalePrefer not to sayOther
• Phone Number *
• Birthday *
• Street address you'd like the lab kit(s) shipped to *

  Note, we don't ship to NJ, NY, and RI at this time.

• City *
• State *Select...AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew MexicoNevadaOhioOklahomaOregonPennsylvaniaSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming
• Zip Code*

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Thank You!

Look out for an email coming from Rupa team soon with instructions and cheat sheets for completing your tests. 👩🔬

Best,

The Rupa Health Team

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