Request for Release of Laboratory Results

July 2023

I hereby request that Quest Diagnostics release to me – via Function Health Inc., as my authorized agent – all completed test results arising out of my receipt of laboratory services from Quest, as accessed via Function Health Inc. (the “Results”).

I hereby acknowledge and accept that: (a) either prior to or simultaneous with the communication of the Results to me, the Results will be communicated to the physician who ordered the laboratory test(s) resulting in the Results (the“OP”); (b) the communication of the Results to me should not be viewed as medical advice and is not meant to replace direct communication with the OP;(c) all inquiries regarding the meaning and/or interpretation of the Results should be directed to the OP; and (d) the communication of the Results does not include any information which would be consideration given for referrals, including medical advice specifically directed at me concerning my condition.