|Comments: Please type or copy the following
in the box to your right: (black text only)
I "TYPE YOUR NAME" give you permission to
charge my credit card $80 for your sevices,
and i understand this is NON-REFUNDABLE.
I also give permission to release my results
to Medlic, LLC or State Boxing Commission.
By filling this out and hitting submit you have agreed
to release your results to us to be distributed to
YOU and/or STATE ATHLETIC COMMISSION
and have your Credit Card charged for the amount listed above.
No one else will see this information. While I understand that
Crawford’s Blood Work and/or USA Blood Work do not encourage
the use of faxing or Emailing as a routine reporting
method of confidential results, I request the use of faxing or emailing
my results to ME and/or STATE ATHLETIC COMMISSION.
I take responsibility for retrieving the results and agree to defend,
indemnify, and hold Crawford’s Blood Work and/or USA Blood Work wholly harmless from and against all costs (including reasonable attorney's fees), liabilities, and expenses arising out of wrongful disclosure, breach of confidentiality of the misuse of my information.