Brain Span Test Kit Activation

You must activate your kit by submitting this form to brainspan@spwestcoast.com prior to sending in your blood drop sample.

The lab will NOT process your sample if you have not activated your test prior to sending it.

Test Kit Serial Number *

Full Name *

First Name Last Name

Gender *

Male Female

Date of Birth *

- Month - Day Year

Practitioner *

Practitioner's E-mail address *

Phone Number *

I Agree to the terms of service & privacy policy *

Yes No

Signature *

Clear

Terms & Conditions

I hereby consent to the collection of a blood sample for the purpose of laboratory testing. By submitting this sample I consent to the testing and authorize the transmission of my laboratory results in any manner, not limited to communication via mail, internet or email.

On behalf of myself and any representatives or heirs, I release BrainSpan, LLC, their affiliates (and any other entity or person associated with the test, and their respective successors, assigns, directors, officers, and employees) from any liability of any kind or nature associated with the collection and testing of my blood sample.

I understand that my results are not a diagnosis of any kind and can be affected by many factors such as recent illness, medications, collection technique or shipping/handling. I agree that this transfer of data does not constitute or create a patient-doctor (or other healthcare professional) relationship between me and BrainSpan, LLC, or its program sponsors or affiliates. I further understand that the results of this test are not meant to diagnose or treat any disease or any other health condition and that this information is not meant as medical advice.